Romola Davenport

When the covid-19 pandemic struck in 2020 there was no stockpile of coronavirus vaccines, and no cure. Instead, governments were forced to fall back on a repertoire of very traditional measures to control epidemics: surveillance, lockdowns, quarantines, and cordons sanitaire. To many people’s surprise, these measures were quite effective in the early stages of the pandemic. Countries that implemented strict quarantines, such as Australia and New Zealand, avoided large outbreaks. In countries with high levels of infection, lockdowns were followed by falling case numbers and deaths.  

Did similar strategies help to control other infectious diseases in the past, before vaccines and antibiotics?  

The answer is a qualified yes. In fact, traditional strategies (quarantines, cordons sanitaire, lockdowns and isolation of victims) were most effective against some of the deadliest and most feared diseases in the past. Examples include plague, smallpox, and typhus. These diseases were brought under control in England by the late 19th century without any advances in cures and, except for smallpox, in the absence of vaccines. The rest of this blog considers the use of control measures against plague and smallpox.   

Plague

Plague was the most terrifying of historical diseases in Europe. The Black Death epidemic of 1347-51 is estimated to have killed a third to one half of the population of western Europe, and the irregular return of the plague was sufficient to suppress population recovery for at least a century.  

Recent advances in recovery and sequencing of ancient DNA have confirmed that the Plague of Justinian (541-49), the Black Death, and subsequent ‘bubonic plague’ epidemics, were caused by the same bacterial pathogen associated with plague in the 20th century: Yersinia pestis.

Analyses of plague genomes from ‘plague pits’ across Europe also support contemporary perceptions that plague was repeatedly introduced into Britain via shipping (rather than becoming permanently established in local rodent populations). That is, plague was an imported disease that was lethal enough to kill healthy adults as well as children, and rich as well as poor (although the rich generally became adept at evasion).  

The historian Paul Slack has argued convincingly that the disappearance of plague from Britain after the 1660s was due to two main factors: (1) better control of plague on the continent, which reduced the frequency with which plague-infected ships reached British ports, and: (2) stricter implementation of maritime quarantines. These quarantine measures included the isolation of ships and cargo suspected of carrying plague for around 40 days (the word derives from the Italian word for forty ‘quaranta’).  

Other more local measures were directed against the spread of plague once it was introduced, such as preventing movement of goods and people from areas suspected of infection, ‘shutting up’ those suspected of infection together with their other household members in their houses or removing the infected to a pest house, and the cancellation of large gatherings, sometimes including church services. Some of these policies were promulgated in Plague Orders issued by the government upon the outbreak of plague, while others were adopted by local authorities on a more bespoke basis. 

The timely issuing of plague orders necessarily depended on surveillance systems to detect plague, both internationally and locally. The most famous of these surveillance systems was the bills of mortality, issued by some of the larger towns in Britain when plague threatened. In London the bills, printed and later fringed with a decorative border of skulls, initially provided a simple count of deaths in each London parish reported in two columns, plague and non-plague.

By the mid-17th century the London bills had developed into routine weekly bulletins that reported counts of burials by different causes, and eventually also by age group (after 1728).     

Did these measures work? In Britain plague does seem to have become to confined mainly to towns by the 16th century, suggesting that at least some of these local measures may have helped to prevent wider dissemination. On the other hand, it is also likely that policies to board up whole households increased mortality in these households.   

Plague elsewhere in Europe

Britain was on the fringes of the continental disease pool, and its island status made it much easier to police the flow of cargos and humans. On the continent, states had to implement much more rigorous control measures to avoid frequent plague outbreaks. Mediterranean ports operated strict quarantine and surveillance policies, sharing information about ships suspected of carrying plague and holding them in quarantine when they arrived.  

On land, some continental European states implemented temporary or permanent cordons sanitaire. Often confused with quarantines, cordons sanitaire refer to attempts to contain plague-affected areas to prevent the transfer of infection. These could be permanent, as in the case of the Habsburg cordon sanitaire that stretched roughly 1900 km along the border between the Austrian and the Ottoman empires in the 18th and 19th centuries. This medical cordon sanitaire was incorporated into an existing militarised border zone, and initially subjected all traffic of people, animal and goods from the Ottoman empire to lengthy quarantines, although this was later moderated in the interests of trade.  

Other cordons sanitaire were temporary, for example the military cordon around Provence instituted by the French crown to contain the last major French plague epidemic in Marseilles (1720-22). The Mur de la Peste, the stone wall built to reinforce the cordon, still survives in sections in the Vaucluse countryside.  

Britain benefited from these continental measures as plague receded from western and central Europe in the late 17th century. The last plague in Scotland occurred in 1647, and in the 1660s in England and Wales. On the continent, the disruption and despoilation of the Great Northern War caused extensive plague outbreaks in the Baltic from 1708-12, and a lapse in quarantine measures led to the last major plague outbreak in western Europe, in Provence in the early 1720s. In the eastern Mediterranean the presence of endemic animal reservoirs of plague meant that plague was much more persistent and difficult to root out.  

Smallpox

While national governments took rapid and often ruthless action to prevent the import and spread of plague (and imported rinderpest in cattle), they made little attempt to control endemic diseases before the 19th century. There were, however, local and uncoordinated efforts to prevent epidemics. In the case of smallpox at least, there is intriguing evidence that these measures were partially successful in reducing the frequency and impact of smallpox in southern England.

Smallpox was an endemic disease in Britain. Before the development of vaccination in 1796, the disease was constantly present in London and the larger towns and circulated through rural areas and small towns at intervals. However, this pattern of circulation differed markedly between southern England on the one hand, and the rest of England and mainland Scotland.  

In the 17th and 18th centuries, epidemics were less frequent in southern England and smallpox caused a smaller proportion of all deaths there (roughly 4 percent in rural communities, compared with 8 percent in northern England). This is puzzling, because at this time southern England was on average more urbanised and more densely populated than northern England, and these characteristics are usually associated with the more rapid transmission of infectious diseases.  

The frequency of smallpox epidemics in northern England meant that smallpox was a childhood disease. As Figure 1 (above) indicates, 90-95 percent of smallpox victims were children aged under 10 years in northern and south-western England. Smallpox infection conferred lifelong immunity on survivors and it was lethal enough to kill otherwise healthy adults. Therefore, the virtual absence of adult victims suggests that almost everyone was infected in childhood.  The comprehensive cause of death records collected by the Swedish state indicate that smallpox was also a childhood disease in late 18th century Sweden, and anecdotal evidence suggests that the same was true of mainland Scotland.  

In southern England the pattern was strikingly different. There, 20-100 percent of smallpox victims were adults. This suggests that smallpox circulated less frequently in southern communities, and that many survived to adulthood without ever encountering the disease.  

What explains this striking north-south pattern? Potential explanations include differences in the ways that deaths were recorded, accidental inoculation with cowpox, and differences in settlement patterns, but statistical tests do not support these possibilities. The most compelling explanation is the deliberate control of smallpox by communities in southern England. Measures included the closure of fairs, markets and courts when smallpox outbreaks were reported nearby, and the isolation of smallpox victims in pest houses (Figure 2 below).  

Pest houses were widely used across Britain to isolate plague victims, however they remained in use in many communities in southern England into the 18th and early 19th centuries to house and nurse parishioners (and sometimes strangers) with ‘contagious distempers’.  

Later in the 18th century the practice of inoculation became popular, especially in southern England. Inoculation involved deliberate infection with smallpox through a cut in the skin, usually on the arm. Infection via this route generally caused a mild case of smallpox that was sufficient to confer immunity against natural infection (which was usually by inhalation).  

In some cases, parish officials organised mass inoculations of all vulnerable parishioners when smallpox threatened – those deemed able to afford it paid a fee, while the poor were inoculated at communal expense. These inoculation campaigns served to reinforce a geographical pattern already established by the use of lockdowns and isolation of victims in the 17th and early 18th centuries. While these measures were not sufficient to prevent smallpox outbreaks entirely, they may have reduced smallpox mortality by as much as half compared with northern England.   

A fascinating corollary of these geographical patterns is that smallpox was a much more feared disease in southern England than in the rest of Britain. Because it could kill adults, and because it was episodic, it excited great fear in southern communities, and infected towns were shunned until they advertised a clean bill of health. In northern England on the other hand, the disease appears to have been an almost unavoidable rite of passage in childhood, and although it caused much higher mortality as a consequence, it did not cause disruption in the same way.

North / South divide  

Why were these practices used in southern England and not in the north? A likely explanation is that they were expensive, and relied on a fairly comprehensive system of parochial welfare. It was expensive to maintain pest houses, to pay for the nursing of smallpox victims, and for mass inoculations. Southern parishes were on average wealthier than in the north, and a greater proportion of parishioners were dependent to some extent on welfare support from the parish.

The strong geographical patterning of per capita welfare expenditures is illustrated in Figure 3 (below) for 1803, and this pattern held broadly across the 18th and 19th centuries. Importantly, not all parishes in southern England took expensive measures to contain smallpox. However the actions of those that did seem to have been sufficient to reduce the wider circulation of smallpox, protecting those parishes that didn’t.

As the archivist J.R. Smith discovered, in some parishes poor law officials debated the relative costs of inoculating parishioners compared with burying them at parish expense and maintaining the families if the breadwinner died. In northern England, on the other hand, most smallpox victims were small children who were nursed at home and whose deaths did not impose an economic burden on the community. Ironically, the measures adopted to control smallpox in southern England serve to perpetuate the costly consequences of smallpox outbreaks, because they succeeded in maintaining smallpox as a disease of adults as well as children. 

Conclusion

The success of public health measures against plague and smallpox serve as a reminder that disease surveillance, quarantines, and lockdowns have a venerable history, and remain important elements of disease control strategies today. As was the case with covid-19, smallpox was only finally brought under control by the advent of an effective vaccine. By the mid-19th century smallpox accounted for less than 1 percent of all deaths in England. However, the disease was only finally eradicated completely by a combination of vaccination and tracing and isolation of sufferers and their contacts, a demonstration of the enduring importance of these very traditional strategies.  

It is also important to recognise that these strategies were most effective against diseases that were not highly infectious, or that were transmitted via pathways that were relatively easy to block. Smallpox was much less infectious than measles, and so even relatively low vaccine coverage had large effects on infection and death rates. It is very unlikely that the use of pesthouses and lockdowns would have helped to reduce measles incidence.  

Similarly, the strategies deployed against covid-19 before the development of vaccines are unlikely to have been so effective against the more infectious variants that emerged later in the pandemic. For highly infectious person-to-person diseases, prevention only became possible with the advent of vaccines.      

Further reading

• Davenport, R., ‘Cultures of contagion and containment? The geography of smallpox in Britain in the Pre-vaccination Era’, in V. Petit, K. Qureshi, and Y. Charbit, et al. (eds.), The Anthropological Demography of Health (Oxford University Press, 2020). https://www.ncbi.nlm.nih.gov/books/NBK565433/ [open access] 
• Slack, P., ‘The disappearance of plague: An alternative view’. The Economic History Review 34(3), 469–476. https://doi.org/10.2307/2595884 
• Smith, J. R., The Speckled Monster: Smallpox in England, 1670-1970, with Particular Reference to Essex (Essex Record Office, 1987). 

Tags: black death, death, disease, plague, quarantine, smallpox, vaccination

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