Frank Snowden, Epidemics and Society: From the Black Death to the Present, Yale University Press, 2019, 682 pages, $35 (hardcover), ISBN 978-0-300-19221-6.

“…concept of the king’s touch to cure disease. King Charles II of England …administered the touch to nearly one hundred thousand people during the mid-1600s.” :(p 31) In the 21st century, the touch of a godman can apparently make kidney stones come out of the mouth, not of the patient, but of the godman himself!

Historian Frank Snowden’s book, Epidemics and Society: From the Black Death to the Present, based on the author’s lectures at Yale University, provides an excellent opportunity to compare Covid-19 with pandemics across two millennia, and to contextualise the similarities/differences of stakeholders’ responses. In a captivating narrative, Snowden first equips us with a basic understanding of diseases, puts us in a time capsule, and takes us back to visualise the horrors as they unfold ‒ microbes plundering humans, humans plundering humans. Demonstrating how pandemics were not “acts of god”, but a consequence of human action ─“every society produces its own specific vulnerabilities”─ asking probing questions, particularly with respect to 21^st century “dress rehearsals” (SARS, Ebola), Snowden uses pandemics as mirrors for humanity.

Covid-19, occurring months after publication of the book, and the responses of societies to Covid-19, confirm the author’s worst fears, not only about our susceptibility to epidemics, (putting to rest mid-20^th century proclamations about the world soon being free of infections), but also how we created additional problems due to a deadly combination of negligence, incompetence, and hubris. While cases/deaths continued to rise, economies crashed, joblessness peaked, and stock markets, shockingly, also peaked, the suffering of non-Covid patient remained largely ignored, creating what some called a “syndemic”.

A digression here: our institute, the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, founded in the early 1960s, had visionary forefathers. For instance, foreseeing the future importance of drug development, the pharmacology department had faculty positions for chemist, basic pharmacologist and clinical pharmacologist! On the other hand, they did not create a department of tropical medicine. Was the belief about victory over microbes so widespread?!

Snowden’s questions about factors (pathogen, morbidity, case fatality rate, symptoms, mode of transmission, age profile of victims) affecting pandemic outcomes are vital – how states respond to pandemics is a question he does not ask here. We can appreciate this question with the wisdom of Covid-19 hindsight as we saw how world leaders often faltered, to the detriment of populations and science, creating a leadership vacuum. This is perhaps a minor shortcoming in this brilliant book, although to be fair, he discusses this elsewhere –

Everywhere, major epidemics caught authorities unprepared, leading to confusion, chaos, … economic activity halted, shops closed, and employment ceased, increasing the threat of hunger and economic ruin. (p 101)

Public responses to pandemics were often severe ─ stigmatisation, scapegoating, flight, mass hysteria, riots, religiosity, cults of saints, and witch-hunts. Scapegoating deserves special mention – foreigners, prostitutes, Jews, dissenters – were “stoned, lynched, and burned”. Snowden gives one particularly disturbing example of genocide when a British Army officer gave smallpox-infected-blankets to Native Americans “to reduce them”. (p 2)

Strained relationships among humans and “compromised standards of living that were ignored in more settled times” were severe consequences of pandemics. Socioeconomic conditions, laissez-faire policies, neoliberalisation, defunding of public health coupled with its privatisation, are recurring themes throughout. It is no coincidence that inequality, presently at the highest level ever, is being extensively discussed. Snowden even uses the almost prohibited-in-the-west “C” word, “What is the class profile of the sufferers”, soon bringing Marx, “philosopher for whom work and environment …were all-important determinants of intellectual, spiritual, and physical health of laborers”. (p 232)

Besides poverty-related (cholera) and “democratic” (influenza) diseases, there were “aristocratic” (tuberculosis) illnesses, although tuberculosis soon became a poverty-related disease. Such a transition also occurred with Covid-19 – starting as a democratic illness among market-goers, it became aristocratic (flyers), ultimately ending up affecting the impoverished to the greatest extent (US data). It would be interesting to compare similar data in relation to “clastoverty” (class, caste, poverty) in India.

Snowden also explores the complex interplay of pandemics with war and ecological disasters, each positively feedbacking the other – the latter threatening existence as we enter a stage of irreversibility. He explains, how, combined together, these disasters impacted human lives, religion, arts, history, medicine, and science.

Science-optimists among us might have been fooled by WhatsApp messages at the start of Covid-19 about closed religious places while hospitals remained open. However, as the pandemic grew, science was backstaged on social media, with ideological superstructures ensuring predominance of (pseudo)remedies, but Snowden tells us this is an old story (“upsurges in religiosity”). “Cures” (which led Sydenham to say that the best physician was the one who did the least), included quinine, herbal mixtures, viper flesh, lemon-flavoured water, exorcism, appeasement of gods, Astrology, stones, cannon firing! As none of these would have worked, it was not surprising that pandemics caused “intellectual disorientation, leaving people bewildered and frightened”. It is interesting to draw parallels with “cures” and higher rates of psychiatric illness (depression, anxiety, substance use, suicides) during Covid.

Pandemics led to the development of public strategies, often “draconian in direct proportion to the magnitude of the perceived threat”, but forming the basis of current approaches – quarantine, contact tracing, isolation, marking/sealing of victims’ houses. One problem with draconian measures was that people tended to hide their disease depriving the authorities of accurate data. This in turn led to states justifying “control over the economy;… movement of people; …surveillance and forcible detention; …extinction of civil liberties”. Fascinating resemblance here, too.

As during Covid-19, some governments in the past instituted relief funds to compensate for lost wages, destruction of personal effects, funeral expenses, although we don’t know much about their practical implementation. Another old strategy ‒ workforce (physicians, barbers, contact-tracers, attendants, gravediggers) recruitment, remained largely unutilised in the neoliberal-era-pandemic even though unemployment peaked.

Another analogy is the role of NGOs and international agencies working with profit-driven firms and being “instruments of soft power to promote US hegemony”. Filling the blanks, we have the Rockefeller Foundation, the UN, DuPont and Monsanto ‒ the 1940s solution to the malaria problem became synonymous with US technology and DDT, denigrating the need to address poverty and environment as promoting socialism. Pharma industry comparisons are interesting too. When the results of the Salk polio vaccine were announced, pharma share prices surged, quite like today! Still, there was not so much stress on patenting, profit-making wasn’t the sole/primary objective; the politician-pharma nexus was yet underdeveloped. Pharma today relies on government funds for research, pocketing the profits, at the expense of society. Snowden is not scared to bring back Marx, who predicted, “need of a constantly expanding market to nestle everywhere, settle everywhere, establish connections everywhere” (p 477), will have adverse outcomes.

The scientists’ response to the current pandemic differs somewhat from the past – oversaturation of therapeutics, rush to publish, (the keyword “Covid-19” gave >75,000 PubMed hits on November 26, 2020), necessitating calls to flatten this curve. While we had A Journal of the Plague Year (1722), a book by Defoe, recounting one man’s experiences of the bubonic plague in London, we now have Coronaviruses, an open-access journal.

Although it is hard to find major omissions in the book, I would like to mention one – in the cholera story ‒ Shambhu Nath De’s discovery of cholera toxin, key to our understanding of the disease and its treatment, and for which many believed he should have got the Nobel. Snowden discusses how the treatment of cholera, particularly oral rehydration solution, evolved – in my opinion this narrative is incomplete without De.

It is tempting to include other issues and similarities – the antivaccine lobby, violence against healthcare workers, woes of non-pandemic-disease-affected patients, conspiracy theories , pharma greed, slavery, fascism, racism, altitude therapy (think hill stations), child labour; but that would take up a whole issue of IJME. Quoting Hegel, psychoanalyst-philosopher Zizek writes in ‘Pandemic!: COVID-19 Shakes the World’, “…the only thing we can learn from history is that we learn nothing from history, so I doubt the epidemic will make us any wiser.” If Snowden writes a post-Covid edition, he might find he has little to add, we repeated all the past mistakes.

This is a book about politics, wars, arts, medicine, public health, and societies, interwoven in a complex network, under the shadow of pandemics.

Above all it is a history of today.

I will end with two quotes from the book:

One of the bitterest ironies of the 2013–2016 crisis is that the expense of combatting the epidemic is estimated to be threefold the cost of setting up a functioning health infrastructure. Such an infrastructure perhaps could have prevented the outburst altogether while providing access to care for other afflictions. Emergency response to contain a conflagration already under way is expensive, inefficient, and inhumane.

In the ancient but pertinent wisdom, salus populi suprema lex esto—public health must be the highest law—and it must override the laws of the marketplace.