Southampton, Hampshire, UK
|London plague victims being buried in 1665, one of nine scenes from John Dunstall’s Plague broadsheet (1666). Credit: Wellcome Collection. (CC BY 4.0)|
Daniel Defoe’s A Journal of the Plague Year is an account of the 1665 Great Plague of London. Based on eyewitness experience, the undersigned initials “H. F.” suggest the author’s uncle, Henry Foe, as its primary source. Published in 1722, it stands as the most reliable and comprehensive account of the Great Plague.1
As of this writing in March 2021, more than 126,000 deaths from COVID-19 have been recorded in the UK and nearly 540,000 in the US.2 The Centers for Disease Control (CDC) predicts that thousands more will die in the next four weeks, despite an ongoing vaccine rollout.3
Machiavelli said, “Whoever wishes to foresee the future must consult the past.” In this spirit, we reflect on the words of Daniel Defoe and the events of the Great Plague of 1665 to see what more we might learn in the present-day fight against COVID-19.
“. . . the plague was chiefly among the poor, yet were the poor the most venturous and fearless of it. . . .”
In popular thought, pandemics do not respect class, striking rich and poor alike. In 1665, the rich withdrew to the country or lived in better accommodations: a relative protection against disease. The poor were not so fortunate.
In 2020, COVID-19 exposed health inequalities related to age, gender, ethnicity, and geography, with higher rates of diagnosis and death in economically deprived, densely populated urban areas. In Chicago, for example, 70% of COVID-19 deaths were in Black citizens, despite being only 30% of the population. Nearly all deaths were in five of Chicago’s most economically deprived neighborhoods.4 Thus, the current pandemic continues to follow the fault lines of inequality; a stark reminder that resources must be concentrated in demographic areas that are most at risk.
|Burying the dead 2020, Drone pictures show bodies being buried on New York’s Hart Island where the department of corrections is dealing with more burials overall, amid the coronavirus disease (COVID-19) outbreak in New York City, U.S., April 9, 2020. REUTERS/Lucas Jackson/File Photo – RC2F2G9E5RDW. Credit: the Thomson Reuters Foundation, the charitable arm of Thomson Reuters.|
“Everybody was at peace; there was no occasion for lawyers, besides . . . they were generally gone into the country. . . . this calamity of the people made them very humble . . .”
In the first wave of the COVID-19 pandemic, there was a great sense of community; a feeling that we were all in this together. For two months, people in the UK stood on their doorsteps to “clap for the NHS.” Will this gratitude for the work of the National Health Service continue post-pandemic? It is difficult to know, but the clapping itself has not survived the second and third waves of COVID-19.
Defoe does not offer much hope on this point: “. . . the general practice of the people was just as it was before, and very little difference was to be seen.” He further observes: “. . . good, pious, and religious people who, when they have had the distemper . . . have forbid their own family to come near them . . . and have even died without seeing their nearest relations . . .” Today, many are still dying alone in ICU beds, separated from their families. Balancing the need for human contact with the risk of infection remains as much of a problem today as it was in 1665.
“The first person died on December 20 or thereabout 1664 but after this we heard no more of any person dying of the plague until 9th February. Then it was hushed . . . for there were no more entered in the weekly bill of the dead until 22 April.”
In pandemics as in war, truth is often the first casualty. This is especially so when politics and medicine interact with partisans who prioritize tribal loyalties over truth. In this process, politicians may become leading sources of misinformation. Suppressing the truth cost lives in 1665 as it still does today.
“. . . the case was this: namely that the infection was propagated insensibly, and by such persons as were not visibly infective, who neither knew when they were infected or who they were infected by.”
Estimates are that more than 50% of new COVID-19 cases come from exposure to infected but asymptomatic individuals.5 The implication is that symptom-based screening will miss some active infections, and that some of these asymptomatic cases will later become symptomatic. The recognition of this dangerous phenomenon makes it important for all persons, not just the sick, to take measures to minimize the spread of disease.
In 1665, this took the form of an exodus of the wealthy from London and distancing from the sick for others. In 2020, this includes practices of social distancing and working from home. In many places, however, people defy this advice because they do not believe in it or their livelihoods depend on ignoring it.
“. . . for though there died still from 1000 to 1800 a week, yet the people flocked to town as if all had been well. The consequence of this was, that the bills increased again 400. . . the people had cast off all apprehensions and that too fast . . .”
The human response to good news after months of social restriction was as predictable in 1665 as in 2020.
“. . . physicians opposed this thoughtless behaviour of the people . . . terrifying them with the danger of bringing a relapse upon the whole city . . .” It proved difficult then, as now, to dissuade people from acting irrationally because they see things as they wish them to be, not as they are. Thus, the second and third waves of COVID-19 were as unsurprising as they were predictable, and underscore the importance of not easing social restrictions too soon despite the inevitable pressures to do so.
“. . . after all was over, yet the distress of the poor was more now a great deal than it was then, because all the sluices of general charity were now shut . . . People supposed the main occasion to be over so stopped their hands . . .”
These words serve as a reminder that the consequences of a pandemic persist long after the disease has settled. As such, governments, even now, need to start preparing to deal with the financial, physical, and mental hardships that will undoubtedly follow.
Daniel Defoe proposed four ideas for managing future plagues:
1. Isolating the sick
“. . . that a method to have removed the sound from the sick . . . would have been much more reasonable . . .”
Test-and-trace should have gone a long way to enable the separation of those who are infected from those who are not. Where implemented properly, it has been effective; however, this process has been inefficient in the UK and US and effectively non-existent in many other countries. Contact tracing depends on trust, and too many citizens do not have enough confidence in their governments to give up their contacts or follow quarantine orders.
“. . . everything was managed with so much care, and such excellent order was observed . . . by the care of the Lord Mayor &c . . . that London may be a pattern to all cities of the world for the good government and excellent order that we everywhere kept . . .”
Without broad-based support and fair implementation of policies, social unrest is, sadly, predictable. Law and order was generally well-maintained in seventeenth-century London, but the same cannot be said for many countries today where COVID-19 has exacerbated existing social tensions.
3. Reducing spread
“. . . the calamity was spread by infection . . . which effluvia affected the sound who came within certain distances of the sick . . .”
The importance of removing possible sources of infection was recognized in the seventeenth century. As knowledge of COVID-19 has increased, we have seen that simple measures such as social distancing, hand cleanliness, and the wearing of masks all help to reduce the spread of disease. These measures alone, if fully implemented, could significantly reduce deaths from COVID-19. However, for some there are barriers to following such advice, and for others the restriction of civil liberties and freedom to gather are held to be more important.
4. Social separation
“. . . on any future occasion of this or the like nature . . . they would consider of separating the people into smaller bodies, and removing them in time farther from one another – and not let such a contagion as this . . . find a million of people in a body together.”
This prescient observation foresees the value of distancing and the creation of “social bubbles” to reduce disease spread. These strategies remain important with the emergence of highly infectious SARS-CoV-2 variants.
“And wonderful it was to see how populous the city was again all of a sudden . . .”
As the Great Plague of 1665 ran its course, so will COVID-19. Effective vaccines serve to bring that day ever closer. However, it would be unwise to place our faith solely in vaccination. Cases of COVID-19 continue to increase in many countries around the world where vaccination levels remain low.2 A recent study by Moore et al suggests that vaccination alone will be insufficient to contain the outbreak in the UK.6 Now, more than ever, we should heed the words of Daniel Defoe and resist premature celebration, remain on our guard, observe simple rules to reduce spread, and be aware that a failure to do so will result in more unnecessary deaths.
We ignore history at our peril.
- Daniel Defoe. A Journal of the Plague Year. Penguin Classics. Ed. 1986 All sentences in the manuscript in italics are direct quotes from this book
- COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
- Centers for Disease Control and Prevention. COVID-19 Forecasts: Deaths Updated Jan 13, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/forecasting-us.html#ensembleforecast
- Yancy CW. COVID-19 and African Americans. JAMA, 2020; 323 (19): 1891-1892
- Johansson MA et al. SARS-CoV-2 Transmission from People Without COVID-19 Symptoms. JAMA Network Open. 2021; 4(1): e2035057. doi:10.1001/jamanetworkopen.2020.35057
- Sam Moore, Edward M Hill, et al. Vaccination and non-pharmaceutical interventions for COVID-19: a mathematical modelling study. The Lancet Infectious Diseases, Published online March 18, 2021 https://doi.org/10.1016/S1473-3099 (21) 00143-2
BRIAN ROBERT PETER BIRCH, MA, MD (Cantab), FRCS, is an Honorary Associate Professor and Consultant Surgeon.