EPIDEMICS

Epidemics may be defined as concentrated outbursts of infectious or noninfectious disease, often with unusually high mortality, affecting relatively large numbers of people within fairly narrow limits of time and space. They probably emerged in human populations with the "Neolithic Revolution," roughly eight to ten thousand years ago, as humans began to domesticate animals, practice agriculture, and settle into towns and villages, with a corresponding increase in the density of population. This entry will cover the history of epidemics with particular reference to their implications for bioethics, beginning with a survey of ancient and medieval times, moving on to responses to epidemics before the nineteenth century, then examining in more detail the impact of cholera and the bacteriological revolution. It will conclude with a discussion of the epidemiological transition and its aftermath, the emergence of new epidemics in the late twentieth century, and the ethical implications of the data surveyed. The focus will be mainly but not exclusively on Europe and North America, where historical source material is richest, and scholarly and scientific studies are most numerous.

Ancient and Medieval Times

Hippocratic texts indicate the presence of tuberculosis, malaria, and influenza in the population of ancient Greece, and the historian Thucydides provides the first full description of a major plague, the precise nature of which remains uncertain, in Athens (430–429 b.c.e.), in his history of the Peloponnesian War. The increase in trade brought about by the growth of the Roman Empire facilitated the transmission of disease, and there were massive epidemics in the Mediterranean (165–180 c.e. and 211–266 c.e.). The "plague of Justinian" (542–547 c.e.), which was said to have killed ten thousand people per day in Constantinople, is the first recorded appearance of bubonic plague (McNeill). In Europe and Asia, diseases such as measles and smallpox gradually became endemic, affecting virtually all parts of the population on a regular basis, with occasional epidemic outbursts. Periodic epidemics of bubonic plague continued, most seriously in the fourteenth century, when perhaps as much as one-third of Europe's population perished.

When Europeans arrived in the Americas, from 1492 on, they brought many of these diseases to native American populations for the first time, with devastating effects. The importation of African slaves introduced malaria and yellow fever by the seventeenth century (Kiple, 1984). The merging of the disease pools of the Old and New Worlds was completed by what appeared to be the transmission of syphilis to Europe from the Americas at the end of the fifteenth century, though the subject remains disputed by historians, some arguing that it was a recurrence or mutation of a disease that already existed on the Continent (Crosby).

Responses to Epidemics before the Nineteenth Century

The ancient Greeks and Romans commonly, though not universally, believed that epidemics were brought into human communities from outside. Thucydides, for example, described the plague that struck Athens during the Peloponnesian War as having arrived by sea. This belief was the basis of official reactions to epidemics in medieval Europe. Following the closure of the port at Venice to all shipping for thirty days as the plague threatened in 1346, regulations imposed in Marseilles in 1384, and in other ports thereafter, prescribed the biblical period of isolation for a "quarantine" (forty days) outside the harbor for any ship thought to have called previously at a place infected with the plague. In 1423 the Venetians set up a hospital where plague victims were isolated, and by 1485 the city had a sanitary authority armed with wide-ranging powers during epidemics. In some epidemics, as in the Great Plague of London in 1665, victims were compulsorily isolated in their own houses, which were marked with a red cross to warn the healthy not to enter. Compulsory screening was not an issue before the late nineteenth century, however, because diseases were recognized as such only after the onset of obvious symptoms, and the concept of the asymptomatic carrier did not exist. In addition to these measures, the authorities in many medieval towns, working on the theory that epidemics were spread through the contamination of the atmosphere, ordered the fumigation of the streets to try to clear the air. Doctors and priests were expected to attend to the sick; and those who fled, as many did, are strongly criticized in the chronicles of these events.

Popular reactions to epidemics included not only flight from infected areas and evasion of public health measures, but also attacks on already marginalized and stigmatized minorities. As bubonic plague spread in Europe in 1348–1349, for example, rumors that the Jews were poisoning water supplies led to widespread pogroms. Over nine hundred Jews were massacred in the German city of Erfurt alone (Vasold). Such actions reflected a general feeling, reinforced by the church, that plagues were visited upon humankind by a wrathful Deity angered by immorality, irreligion, and the toleration of infidels. A prominent part in these persecutions was played by the flagellants, lay religious orders whose self-flagellating processions were intended to divert divine retribution from the rest of the population. Jews were scapegoated because they were not part of the Christian community. Drawing upon a lengthy tradition of Christian anti-Semitism, which blamed the Jews for the killing of Christ, the people of medieval Europe regarded Jews at such times as little better than the agents of Satan (Delumeau).

State, popular, religious, and medical responses such as these remained essentially constant well into the nineteenth century. The medical understanding of plague continued throughout this period to draw heavily on humoral theories, so that therapy centered on bloodletting and similar treatments designed to restore the humoral balance in the patient's body. They were of limited effectiveness in combating bubonic plague, which was spread by flea-infested rats. The isolation and hospitalization of victims also therefore did little to prevent the spread of plague. Nevertheless, the disease gradually retreated from western Europe, for reasons that are still imperfectly understood. The introduction of more effective quarantines with the emergence of the strong state in the seventeenth and eighteenth centuries was almost certainly one of these reasons, however, and helped prevent the recurrence of epidemics in the seventeenth and eighteenth centuries (Vasold).

State intervention also played a role in reducing the impact of smallpox, the other major killer disease of the age after bubonic plague. Its spread was first reduced by inoculation, before compulsory programs of cowpox vaccination brought about a dramatic reduction in the impact of the disease in nineteenth-century Europe. Despite the imperfections of these new methods, which sometimes included accidentally spreading the disease, vaccination programs in particular may be regarded as the first major achievement of the "medical policing" favored by eighteenth-century absolutist monarchies such as Prussia. Police methods that paid scant attention to the liberties of the subjects were used to combat the spread of epidemics. They included the use of troops to seal off infected districts, quarantines by land and sea, and the compulsory isolation of individual victims. Most of these measures had little effect, however, either because of lack of medical knowledge or because poor communications and lack of police and military manpower prevented them from being applied comprehensively (Rosen).

The Impact of Cholera

These theories and practices were brought into question above all by the arrival in Europe and North America of Asiatic cholera. The growth of the British Empire, especially in India, improved communications and trade, and facilitated the spread of cholera from its base in the Ganges delta to other parts of Asia and to the Middle East. Reaching Europe by the end of the 1820s, the disease was spread further by unsanitary and overcrowded living conditions in the rapidly growing towns and cities of the new industrial era. At particular moments of political conflict, above all in the European revolutions of 1830 and 1848, the AustroPrussian War of 1866, and the Franco-Prussian War of 1870–1871, it was carried rapidly across the continent by troop movements and the mass flight of affected civilian populations (Evans, 1988).

Cholera epidemics affected the United States in 1832, 1849, and 1866, on each occasion arriving from Europe in the aftermath of a major conflict. State, popular, and medical responses in 1830–1832 were unchanged from earlier reactions to epidemics. Quarantine regulations were imposed, military cordons established, victims isolated, hospitals prepared. In Prussia, the breaching of such regulations was made punishable by death. But the opposition that such measures aroused among increasingly powerful industrial and trading interests, and the feeling among many liberals that the policing of disease involved unwarranted interference with the liberty of the individual, forced the state to retreat from combating cholera by the time of the next epidemic, in the late 1840s. In addition, medical theories of contagion were brought into disrepute by the failure of quarantine and isolation to stop the spread of the disease in Europe. Until the 1880s, many doctors thought that cholera was caused by a "miasma" or vapor rising from the ground under certain climatic circumstances. It could be prevented by cleaning up the cities so as to prevent the source of infection from getting into the soil (Evans, 1987). This was a contributory factor in the spread of sanitary reform in Europe and the United States during this period. But its importance should not be overestimated. Boards of health established in American cities in the midst of the cholera epidemics of 1832 and 1849 were short-lived and of limited effectiveness, and even in 1866 the more determined official responses had less to do with the impact of cholera than with the changed political climate (Rosenberg).

The fact that cholera affected the poorest sectors of society most profoundly was the result above all of structural factors such as unsanitary and overcrowded living conditions, unhygienic water supplies, and ineffective methods of waste disposal. But state and public responses to epidemics in the nineteenth century, at least in the decades after the initial impact of cholera, were primarily voluntaristic. Religious and secular commentators blamed cholera on the alleged immorality, drunkenness, sexual excess, idleness, and lack of moral fiber of the victims. Fast days were held in eleven New England states in 1832, in the belief that piety would divert God's avenging hand. Once again, the socially marginal groups of industrial society, from vagrants and the unemployed to prostitutes and beggars—or, in the United States in 1866, the newly emancipated slaves and the newly arrived Irish immigrants—were blamed (Rosenberg).

The rise of the medical profession, with well-regulated training and a code of ethics, ensured that doctors were more consistently active in treating victims of epidemics in the nineteenth century than they had been in previous times. Partly as a result, there were popular attacks on the medical profession in Europe during the epidemic of 1830–1832. Angry crowds accused doctors of poisoning the poor in order to be able to reduce the burden of support they imposed on the state or, in Britain, in order to provide fresh bodies for the anatomy schools (Durey). As late as 1892, doctors and state officials were being killed in cholera riots in Russia (Frieden). There were also disturbances in the United States, where a hospital was burned down in Pittsburgh and a quarantine hospital on Staten Island, in New York City, was destroyed by rioters fearing the spread of yellow fever. However, in most of Europe, public disturbances caused by epidemics had largely ceased by the middle of the nineteenth century. Fear of disorder was another reason for the state's withdrawal from policing measures (Evans, 1988). In Europe, too, religious responses to epidemics had become less important by the end of the century as religious observance declined. In 1892, however, as cholera once more threatened America's shores, it fed nativist prejudice and led to the introduction of harsh new restrictions on immigration.

The Bacteriological Revolution

Cholera was only the most dramatic of a number of infectious diseases that took advantage of urbanization, poor hygiene, overcrowding, and improved communications in the nineteenth century (Bardet et al.). Typhus, typhoid, diphtheria, yellow fever, tuberculosis, malaria, and syphilis continued to have a major impact, and even smallpox returned on a large scale during the Franco-Prussian War of 1870–1871. Treatment continued to be ineffective. But the rapid development of microscope technology in the last quarter of the century enabled medical science to discover the causative agents of many infectious diseases in humans and animals. Building on the achievements of Louis Pasteur, Robert Koch identified the tubercle bacillus in 1882 and the cholera bacillus in 1884. These discoveries marked the triumph of bacteriology and completed the swing of medical opinion back from belief in "miasmas" as causes of epidemics toward a contagionist point of view.

From the 1880s, states once more imposed quarantine and isolation, backed by preventive disinfection. The greater effectiveness of state controls, compared with the earlier part of the century, was combined with the more precise focus on eliminating bacterial organisms. Once the role of victims' excretions in contaminating water supplies with the cholera bacillus became known, it was possible to take preventive action by ensuring hygienic water supplies and safe waste disposal. By the outbreak of World War I in 1914, the role of the human body louse in spreading typhus, and that of the mosquito in transmitting malaria and yellow fever, had been identified. Mosquito control programs were launched by the U.S. Army in Cuba following the Spanish-American War of 1898, and subsequently in the Panama Canal Zone, in order to reduce the incidence of yellow fever cases to an acceptable level. Regular delousing reduced typhus among armies on the western front in Europe during World War I. The Japanese army prevented casualties from typhoid and smallpox by a campaign of systematic vaccination during the war with Russia in 1904–1905 (McNeill; Cartwright).

The bacteriological revolution thus inaugurated an age of sharply increased state controls over the spread of disease. Laws were introduced in many countries making the reporting of infectious diseases compulsory. The growth of a comprehensive, state-backed system of medical care, working through medical officers, medical insurance plans, and the like, made comprehensive reporting easier. Hospital building programs in the second half of the nineteenth century facilitated the isolation of victims in hygienic conditions where they could be prevented from spreading the disease. The greater prestige of the medical profession in most industrialized countries by the late nineteenth and early twentieth century ensured that doctors were no longer attacked, and that the necessity of compulsory reporting and isolation was widely accepted by the public. However, a bacteriological understanding of disease causation also involved a narrowing of focus, in which increased emphasis was placed on the compulsory reporting of cases, followed by their isolation, at the expense of broader measures of public health and environmental improvement (Porter).

The Epidemiological Transition

Lower death rates from diseases such as cholera, typhoid, and tuberculosis were only partially the consequence of bacteriologically inspired state preventive measures, and the disease burden from acute infectious disease began to decline rapidly. The provision of clean, properly filtered water supplies and effective sewage systems reflected growing municipal pride and the middle-class desire for cleanliness. It made epidemics such as the outbreak of cholera that killed over eight thousand people in Hamburg, Germany, in little over six weeks in the autumn of 1892 increasingly rare. Just as important were improvements in personal hygiene, which again reflected general social trends as well as the growing "medicalization" of society in western Europe and the United States. Such developments reinforced the stigmatization of poor and oppressed minorities as carriers of infection, since they were now blamed for ignoring official exhortations to maintain high standards of cleanliness, even though their living conditions and personal circumstances frequently made it difficult for them to do so. Particular attention was focused on working-class women, who were held responsible by official and medical opinion for any lack of hygiene in the home (Evans, 1987).

The development of tuberculin by Koch in 1890 made possible the compulsory screening of populations even for asymptomatic tuberculosis. This was increasingly implemented after 1900, in conjunction with the forcible removal of carriers to sanatoria, although this was more effective in isolating people than in curing them. Educational measures also helped reduce the spread of the disease. The development and compulsory administration in many countries of a preventive vaccine against tuberculosis from the 1920s aroused resistance among the medical community, not least because by creating a positive tuberculin reaction in noncarriers, it made it impossible to detect those who truly had the disease, except where symptoms were obvious. These measures had some effect in reducing the impact of the disease. However, although the precise causes of the retreat of tuberculosis remain a matter of controversy among historians, the long-term decline of the disease from the middle of the nineteenth century was probably more the result of improvements in housing, hygiene, environmental sanitation, and living standards than of direct medical intervention. The introduction of antibiotics such as streptomycin after World War II proved effective in reducing to insignificant levels mortality from a disease that had been the most frequent cause of death or disability among Americans aged fifteen to forty-five (Dubos and Dubos).

Similarly, official responses to syphilis centered, especially in Europe, on the forcible confinement of prostitutes to state-licensed brothels or locked hospital wards, where they were subjected to compulsory medical examination. Before World War I, New York, California, and other states had introduced compulsory reporting of cases of venereal disease, and official concern for the health of U.S. troops led to the jailing of prostitutes. Measures such as these had no discernible effect on infection rates, which rose sharply during the war. They also represented a serious restriction on the civil liberties of an already stigmatized group of women, while the men who were their customers, and equally active in the sexual transmission of disease, were regarded as irresponsible at worst, and were not subjected to similar measures. The development of Salvarsan (arsphenamine) by Paul Ehrlich in 1910 introduced the possibility of an effective treatment for syphilis. But here again there was resistance, both within the medical community and from outside, from those who considered that an increase in sexual promiscuity would be a result. This view became even more widespread following the use of penicillin on a large scale during World War II (Brandt).

Epidemics of the Late Twentieth Century

In the West, epidemic infectious disease was regarded by the second half of the twentieth century as indicating an uncivilized state of mind, and was ascribed above all to nonwhite populations in parts of the world outside Europe and North America. This reflected structural inequalities in the world economy, as the great infections became increasingly concentrated in the poor countries of the Third World. By the middle of the twentieth century, however, rapidly increasing life expectancy was bringing rapid growth of noninfectious cardiac diseases, cancer, and other chronic conditions that posed new epidemic threats to an aging population in the affluent West. Under increasing pressure from the medical profession, the state responded not only with education initiatives but also with punitive measures directed toward habits, such as cigarette smoking, that were thought to make such conditions more likely. The arsenal of sanctions governments employed included punitive taxation on tobacco and the banning of smoking, under threat of fines and imprisonment, in a growing number of public places. Increasingly, institutions in the private sector also adopted these policies. They raised the question of how far state and nonstate institutions could go in forcing people to abandon pleasures that were demonstrably harmful to their own health. At the same time, they contrasted strongly with the reluctance of many states and companies to admit responsibility for cancer epidemics caused by factors such as nuclear weapons testing, the proximity of nuclear power stations to human populations, or the lack of proper precautions in dealing with radioactivity in industrial production.

In the 1980s, the identification of a new epidemic, known as acquired immune deficiency syndrome (AIDS), once more raised the ethical problems faced by state and society, and by the medical profession, in the past. Lack of medical knowledge of the syndrome and the danger of infection from contact with blood or other body fluids, posed the question of whether the medical profession had a duty to treat AIDS sufferers in the absence of any cure. The evidence of the overwhelming majority of past epidemics, for which there was also no known cure, seems to be, however, that medical treatment, even in the Middle Ages, could alleviate suffering under some circumstances, and was therefore a duty of the practitioner. In a condition that could prove rapidly fatal, the ethics of prolonged tests of a drug such as AZT, in which control groups were given placebos, was contested by AIDS sufferers anxious to try anything that might possibly cure the condition, or at least slow its progress.

If this was a relatively novel ethical problem, then the question of compulsory public-health measures was a very old one. Like the sufferers in many previous epidemics, AIDS victims tended to come from already stigmatized social groups: gays, drug abusers and prostitutes, Haitians and Africans. The ability to screen these high-risk groups for the presence of the causative agent, the HIV retrovirus, even at the asymptomatic stage, raised the possibility of compulsory screening measures, quarantine, and isolation. On the other hand, individuals publicly identified as HIV-positive generally found it difficult or impossible to stay employed, to obtain life or health insurance, or to avoid eviction from their homes. In the absence of adequate supportive measures, public-health intervention reinforces existing discrimination against these groups, as in many past epidemics.

An alternative state response has consisted of neglect, on the assumption that AIDS is unlikely to affect the heterosexual, non-drug-abusing, nonpromiscuous majority of the voting public. It is noticeable that, generally, politicians have invested resources in public education and other preventive measures only when they have believed that the majority population is at risk. These problems have been raised again by the recent resurgence of tuberculosis in Western countries, among the HIV-positive but also among the poor and the homeless. Drug-resistant strains of the disease have become common, and the transient, jobless, and destitute have neither the means nor the stability of lifestyle to complete the lengthy course of drugs that is necessary to effect a cure. The compulsory isolation of victims and their forcible subjection to a course of treatment is not a satisfactory long-term solution to the problem, since reinfection is likely upon release, unless the social and personal circumstances of the affected groups undergo a dramatic improvement.

Conclusion: Ethical Implications

The history of epidemics suggests that society's responses have usually included scapegoating marginal and already stigmatized groups and the restriction of their civil rights. From the Jews massacred during the Black Death in medieval Europe, through the beggars and vagrants blamed for the spread of cholera in the nineteenth century, to the prostitutes arrested for allegedly infecting troops with syphilis during World War I, and the minorities whose life-styles were widely regarded as responsible for the spread of AIDS in the 1980s and 1990s, such groups have frequently been subjected to social ostracism and official hostility in times of epidemic disease. Frequently, though not invariably, they have been the very people who have suffered most severely from the disease they were accused of spreading. Doctors have sometimes been reluctant to treat them; the state has often responded with punitive measures.

At no time have public-health measures to combat epidemics been politically uncontested. Nineteenth-century feminists, for example, campaigned vigorously against the state's restriction of the civil liberties of prostitutes in the name of disease control. The fact that their male customers were left free to spread sexually transmitted diseases unhampered by the attentions of the state implied an official endorsement of different standards of morality for men and for women, and it was this major structural element of the social value system that the feminists were seeking to change. Without such change, not only was medical intervention ethically indefensible, but there would never be any likelihood of effective control of sexually transmitted diseases. Similarly, many nineteenth-century epidemics, such as cholera or tuberculosis, were spread by poor nutrition, overcrowded housing, and inadequate sanitation. Social reformers therefore regarded major improvements in these areas as more important than direct medical intervention through measures such as compulsory hospitalization.

Epidemics are frequently caused by social and political upheavals. In the past, movements of large masses of troops and civilians across Europe, from the Crusades to the Crimean War, brought epidemics in their wake. In the early 1990s, a major cholera epidemic broke out in Peru as the result of the flight of thousands of peasants from their mountain settlements, driven out by the pitiless armed conflict between the army and the "Shining Path" guerrillas, to the narrow coastal strip, where they lived in makeshift shantytowns with no sanitation. Economic crisis and the dismantling of welfare measures for the homeless, the mentally disturbed, and the destitute in many Western countries in the 1980s contributed to a massive increase in the transient population on the streets of the great cities. Discrimination against AIDS sufferers by landlords and employers has added to this problem. By the early 1990s there were an estimated ninety thousand homeless on the streets of New York City, half of whom were HIV-positive and several thousand of whom were suffering from tuberculosis. Any long-term solution to these epidemics must be more than merely medical, as must any explanation of their occurrence. Public-health measures are thus inevitably political in their implications, since they can be considered and administered only with reference to the wider social and cultural context within which the disease they seek to prevent or control has originated.

richard j. evans (1995)

bibliography revised

SEE ALSO: AIDS; Bioethics, African-American Perspectives; Bioterrorism; Care; Communitarianism and Bioethics; Human Rights; Literature and Healthcare; Medical Ethics, History of Europe; Narrative; Public Health, History; Public Health, Philosophy; Sexual Behavior, Social Control of

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