In a lot of ways this pandemic is hashtag not-that-bad. Particularly in comparison to the plagues which swept through Asia, northern Africa, and Europe in the 14th century killing possibly as many as 200 million people (somewhere between 30–50% of the population), a pandemic with a mortality rate of 0.66–7.8% depending on your age is comparatively less devastating.
Additionally, unlike with the Black Plague we know what we’re doing. Sort of. There are, unfortunately a lot of people who think they can literally cheat death and those people are driving infection rates, but we have made considerable advances in germ theory since the 14th century.
Modern medicine does help quite a bit. During the outbreaks of what we believe was bubonic plague in medieval Europe the consensus was that infectious disease was transmitted via miasmas of bad air, and that one could counteract such miasmas with good smells. Hence a “pocket full of posies.” This is additionally why medieval plague doctors often had those strange masks. The beak over the nose was filled with dried flowers and it was believed that this would keep the wearer safe.
The idea of miasmas persisted for centuries probably in part because for some diseases it is actually somewhat accurate. Even I cannot smell a virus on the air so it is not as if the smell itself is a vector for disease, but there do exist airborne diseases and some of them can be fatal. Like Covid-19 and measles. But hashtag not all infectious diseases.
John Snow in 1855 proved that a cholera outbreak was the result of a contaminated water supply as opposed to a miasma. Cholera rates decreased rapidly after the water supply in Soho was decontaminated, and while opponents of his theory vociferously objected, it was eventually agreed — largely due to the scientific rigor of Snow’s study — that his theories on disease vector were correct. Evidently, the statement, “you know nothing, John Snow,” is wrong.
So let’s talk briefly about disease vectors for Covid-19 and Yersinia pestis. Covid-19 involves human to human transmission. It is viral, it can be airborne and it can survive — as much as a virus is considered alive — on a surface for about an hour. This is why I’ve said in other places that the rate of inoculation is going to need to be 90–95%. Covid-19 may not have a super high mortality rate, but it does have a rather high rate of infection. It’s easy to get.
Yersinia pestis however is bacteria and requires an ectoparasite — usually the flea Xenopsylla cheopis — for transmission. The standard theory had been until about 2017 that such fleas carried on black rats were transmitted along trade routes from northern China and Mongolia where the disease originates to Europe and there went more or less hog wild because Europe was far more urban than the Asian steppe and there were rather rat friendly environments.
However, for one not all the places in which bubonic plague outbreaks occurred were black rat friendly, and the rate of transmission was mathematically determined to be too high for specifically and only the fleas on black rats to be the vector. Probably Y. pestis may be transmitted by other ectoparasites like lice which allows for almost human to human transmission.
Adding to this, while quarantine, hygienic, and mask wearing efforts are clearly efficacious for lowering the rate of Covid-19 transmission, similar measures were undertaken during plague outbreaks to varied effect. The plague masks were clearly not helpful on their own but they were often worn with other protective garb which at least decreased the likelihood that the wearer would be bitten by an ectoparasite. Hygiene was a bit different at the time, but the idea of miasma meant that particularly during and after the first outbreak there was a concerted effort to keep garbage, discarded offal, dead animals, and faeces off the streets and away from living areas thereby reducing contact between humans and rats. And there were definite impositions of quarantine.
In extreme cases particularly in urban areas and particularly pertaining to poorer communities families were sometimes boarded up in their homes if one showed plague symptoms. If Y. pestis was only transmitted via fleas that could only live on rats then it might have been a relatively simple matter for that family to do a deep clean of their house and remove bedding or clothing or garbage where rats and their fleas could hide and proliferate.
People who could afford to do so left for the country to quarantine away from cities. And that did seem to work. Communities which entirely cut themselves off from the outside world did considerably lower their rates of infection, transmission, and mortality. So the vectors for bubonic plague and Covid-19 are quite different, but prior to the development of treatment or vaccination, quarantine and social distancing measures are some of the best ways to lower the rate of transmission.
Enter: the Economy
For both Covid-19 and the bubonic plague pandemics trade routes is how all of this was started. And for both Covid-19 and the bubonic plague the economy will be and was seriously altered as a result. Therein largely end the similarities.
Despite the relatively high population density of Europe as compared to Asia particularly the Asian steppe at the time, Europe’s economy was largely agrarian based. And as this was well prior to the industrial revolution, it was human labour which drove the economy. Those who worked the land often did not own it but were paid for their labour by those who did. That pay prior to the plague was quite low. But after the plague swept through Europe and killed some 30–50% of the population, workers were able to command much higher fees simply because labour was so scarce. There was little landlords could do about this besides complain. If they did not pay their surviving tenants higher wages those workers could simply find a lord who would.
But the reason it worked out this way is because bubonic plague was not terribly selective in terms of age. It did seem to kill a higher proportion of older individuals, but young adults particularly 20–25 year olds were also susceptible. (I will explain why this is in the next section.) This meant that elderly who might not have been able to work in the fields anymore were not the only ones dying. Young presumably robust people who would have been seen as choice workers were also susceptible to the high mortality rate.
But Covid-19 is behaving very differently. The speculative nature of mortality estimates for the medieval plague epidemics are due to a lot of unknowns. Records were not inclusive, there were likely different mortality rates in different populations, and there would have been some difference in rates of infection and mortality for urban and rural populations. For Covid-19 we have considerably better data. The case fatality rate (CFR) for Covid-19 in young people is about 0.66%. In the elderly the CFR jumps to 7.8%. That is very different from the bubonic plague.
Additionally, because the American economy is — or at least was prior to the pandemic — a service based economy, young people are not necessarily the most sought after workers as they would be in an agrarian economy. Six sectors cited as suffering or likely to undergo major changes in the next year are the auto industry, the restaurant industry, banks, insurance (for somewhat obvious reasons), healthcare, and higher education. Covid-19 being incredibly contagious will continue to force the world at large into quarantine until we have and may manufacture and distribute a vaccine. Pfizer has had good results for which, predictably, Trump is trying to take credit however spurious his reasoning, but manufacture and distribution will still take time during which many people will not be able to work and may find their jobs eliminated with advancing automation.
There may not be a “normal,” to return to.
It is fortunate that not as high a proportion of our population has passed due to Covid-19, but the economic effects on individual workers particularly young people will be devastating.
Survival Post Pandemic
This is the part that to me is genuinely the most concerning. There are about three seminal works by or involving one Sharon DeWitte that more or less explain mortality profiles during the black death and health post-plague. They’re kinda difficult to explain unless you’re familiar with the osteological paradox, but basically when you’re looking at cemetery populations you have to remember that while these individuals may or may not have various lesions and so forth remaining on their skeletons that you can see and which were formed in life these individuals are now dead. And I know that sounds obvious but said lesions take time to form, may heal, or may become the cause of later difficulties. So if you’re looking at the skeleton of a young person who seems healthy … well, obviously they’re not … because they’re dead. Conversely if you have the skeleton of a clearly elderly individual that looks absolutely jacked (that’s the proper medical term in case you were wondering) in every possible way you might posit that they were unhealthy, but you have to remember that they survived until whatever age they died. Again, seems obvious, but it’s easy to forget.
I did promise to tell you what was happening with those young people who died during the black plague. I said the bubonic plague was not all that selective. Well, I kinda lied. It did kill a lot of people regardless of age, but the reason there was a death spike among young people seems to be associated with their health and nutrition earlier in their lives. The young women and men who died from the bubonic plague in Europe tended to have a higher rate of stress indicators on their skeletons. This means growing up they maybe didn’t get enough food or experienced one too many childhood diseases and while they survived into early adulthood, they weren’t as strong as they might have seemed and the plague was able to take them.
With Covid-19 we are seeing — fortunately to a far lesser degree — a similar pattern bearing out. Particularly in America people from underserved populations are more likely to die or experience “long Covid.”
The difference is after the black plague, quality of life mostly got better for people. And yes, this is a function of so many people dying of bubonic plague, but we also have a very different structure of government and economy. It is not necessary that a catastrophic event occur for us to care for the less fortunate among us.
With Covid-19 it’s going to be the exact reverse. Some people get lucky with this monster. Some people get it, get over it and move on with no problem. A small proportion do die, but I’m additionally concerned for those who get the longer form of this illness requiring hospitalization and a higher level of intervention. In some cases they may fully recover in a few months or maybe a year out. We don’t know: this thing hasn’t actually been around that long. But what if people who caught this and whose immune systems reacted poorly end up with chronic illness?
We have to take care of these people — that is not a question — the question is how much of our resources going forward need to go towards their care and how much will their lives and quality of life be disrupted? It’s possible, however unlikely that they’ll all recover within a year and this will just be an awful thing we all collectively went through many of us losing someone dear. But it’s more likely that some of the people who survived, particularly those who suffered strokes, may find themselves with new and permanent disabilities like partial blindness, paralysis, chronic fatigue, or maybe even auto-immune disorders. There may be permanent lung damage in some Covid-19 patients for whom we will have to adjust our world.
The Black Death had a considerably higher mortality rate and we are truly lucky that we did not go through a pandemic like that. But health outlooks for survivors of our modern pandemic are going to be very different. This is something our society will have to address from the top of government all the way down to individual families.
Even once we’ve eradicated this bug we are facing a whole new world.