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1 The Public Sphere and Health Communication in the Context of Emergent Infectious Diseases
Part 1 Historic memory of epidemics and vaccines
Desperate in view of the mounting death toll, which by August 1577 had reached around 10,000 (Cohn Jr, 2010), the people of Milan vowed to build a temple and dedicate it Saint Sebastian if he succeeded in purging the curse of the Black Death from their city. Saint Sebastian was the patron saint of plague. It was believed that the plague of 680 that had struck northern Italy nearly a thousand years earlier, had stopped only after a relic of the saint’s arm was moved from Rome and set up in the Church of San Pietro in Vincoli in Pavia. The foundation stone of the new temple in Milan was laid in September 1577, and on January 20, 1578, on the Feast of Saint Sebastian, the plague was officially declared to have passed. To this day, the cylindrical temple, located near Milan’s Duomo, symbolizes pain and rebirth from darkness and death.
In Bristow’s book, American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic (2012), the author argues that the Americans have developed a “national amnesia,” erasing the dark days of pandemic from their collective memory, in order to compose an optimistic narrative. Yet, the echoes of the great epidemics and the death they entail are never really erased from our collective memory. They may indeed be buried deep in the storerooms of our mind, but just as the Milanese brought back the memory of an ancient plague in 1577 that had struck nearly a thousand years earlier to help them cope with the new incidence of the plague, we revive memories of previous epidemics each time a new one strikes.
Epidemics as a metaphor for societal ills
While other illnesses that have killed and disabled many millions, such as malaria, can be explained as an inevitable part of poor living conditions, an epidemic is a disease that literally “falls upon people” (in Greek, epi means “upon or above,” and demos means “people”) (Cunningham, 2008). It strikes indiscriminately and is by definition episodic and unpredictable. As a result, epidemics are highly visible and much more frightening, and thus have a special cultural salience (Rosenberg, 2008).
Memories of previous epidemics are expressed in various and diverse cultural representations. They are depicted in many historical monuments and architectural creations throughout the world, in paintings, in sculptures, in engravings and in photography, and rendered through music and dancing. They are also present in literature, as well as in theater and cinema (Vidal et al., 2007). Epidemics, as they are articulated in all these artistic expressions, symbolize our sense of helplessness in the face of uncertainty and death, as well as the arbitrary nature of death itself. More importantly, they can be seen as a mirror of society’s internal chaos– the social, political, even theological ills. The heroes of many works that portray epidemics are in many cases healers, who, with their therapeutic talent, compassion and altruism, try to fight evil or treat the sick.
One pre-eminent example is The Plague by Albert Camus, which tells the story of a plague that strikes the Algerian city of Oran, and of the collective response to the catastrophe. It is believed that the novel is based on a real event – the great cholera epidemic in 1849, which killed a large percentage of the population of Oran (Mitchell, 2012). Yet, the novel, published in 1947 – in the wake of World War II, can be read as an allegory symbolizing the ills of a society infected with complacency, evil, and denial, and of human suffering in an indifferent world. Its heroes, Dr. Rieux and his friends Tarrou and Grand doggedly battle the plague, rebelling against the senselessness of death. Despite the knowledge that the disease is incurable, Dr. Rieux does not abandon his patients, providing them with care and exceptional compassion.
Another example that connects the ancient and the modern world is Connie Willis’ novel Doomsday Book (Willis, 1992). The story takes place England in both the mid-21st century, and the 14th century. Due to the collapse of the time travel coordinates for her trip, the protagonist, Kivrin Engle, a time-traveling historian, is caught in a small medieval village in England during the Black Death epidemic in 1348, hoping to be rescued by her colleagues from Oxford of the 2050s. Eventually, the epidemic strikes the modern world and threatens it. The significance of the story is clear: the time traveler is a heroine who struggles to unify two different and yet similar worlds.
Homer’s Iliad also incorporates reference to an epidemic. The first poem describes how Apollo, furious at King Agamemnon for refusing to return his priest’s daughter, sends a fatal plague upon the Greek army, causing the death of many soldiers: “a plague sent down by the lines of his arch.”
In The Decameron, Giovanni Boccaccio’s most famous literary work (Boccaccio, 1973), the plague is used as a satiric metaphor to expose the injustices and crimes of various religions. The book is a collection of stories, whose depictions of sexuality, lust, and betrayal criticize religion and clergymen.
In the theater, perhaps the most famous play describing an epidemic is Oedipus the King, Sophocles’ tragedy. Following a vicious murder, a lethal plague strikes the city of Thebes. Plants, animals, and people are all dying. Devoted to his people, Oedipus tirelessly tries to find the cause of the plague. Tragically, as his investigation progresses, he discovers the bitter truth – the failure of his attempts to fight his destiny and prevent the fulfillment of the prophecy according to which he was supposed to kill his own father and marry his mother, and so he himself was cause of the plague. Thus, the plague serves as a catalyst for identifying Oedipus’ original sin. It is a metaphorical expression of the inner plague in Oedipus’ soul.
In many creations related to the Black Death, a central motif which was popular in the late-medieval period is the Dance of Death (in French: La Danse Macabre), in which skeletons who represent death force the living to dance with them (Christian, 2011). The Dance of Death has both literary and visual representations in drama, poetry, music, paintings, engravings, and sculptures. Its purpose is to remind viewers and readers of the universality of death and of their own mortality (Oosterwijk, 2009, 2012). Striking examples include Hans Holbein’s woodcuts, first published in 1538 (Byrne, 2006), and the “Imago mortis,” a woodcut made in 1493 by the German painter and printmaker, Michael Wolgemut, inspired by the horrors of the Black Plague (Oosterwijk, 2012). Wolgemut, like Holbein and many others who portray the Dance of Death, illustrates the figure of death encroaching on life. Just as in ancient and modern books, novels and poems, the epidemic unifies past and present, the inside and the outside world. Death is indiscriminate, striking both young and old, the poor and the rich, nobles and commoners, and all of them, regardless of class, gender or religion, join the Dance of Death in awe.
In the cinema, Vidal, Tibaruenc and Gonzalez (Vidal et al., 2007) identify 100 films that portray infectious diseases. Well-known examples include Death in Venice (Luchino Visconti, 1971), which represented a cholera epidemic; The Seventh Seal (Ingmar Bergman, 1957), portraying the Black Plague; and Outbreak (Wolfgang Petersen, 1995), featuring an Ebola-like virus. Pappas, Seitaridis, Akritidis, and Tsianos (2003) reviewed films focusing on epidemics, and found that most of them focus on the threat presented by outbreaks. Among the films they reviewed are 1918 (Ken Harrison, 1985), which focused on the 1918 influenza epidemic; Gypsy Fury (Christian Jacques, 1949), which described the Black Death; Trollsyn (Ola Solum, 1994) and Dr. Bull (John Ford, 1933) – two films that portrayed typhoid epidemics.
All of these films represent an attempt to find a way to deal with the lack of control and the uncertainty that characterize epidemics. For example, in Death in Venice, the main character, Gustav von Aschenbach, struggles with an overwhelming attraction to a 14-year-old boy. In The Seventh Seal, the hero embarks on an inner journey in view of the raging epidemic, and searches his soul, while the characters struggle with passion and fantasies.
Thus, many artists, in various fields of art, have chosen to use epidemics and their unpredictable, threatening, and devastating power to articulate the destructiveness within human society. In many works, the epidemic symbolizes the social consciousness of evil and death and the struggle against them.
The memories of previous epidemics are also very prominent in the mass media. Each time a new outbreak strikes, the news is inundated with stories of past pandemics. The most recent example is the Ebola epidemic in West Africa. In October 2014, after the death of Thomas Eric Duncan, the first Ebola patient to be diagnosed on US soil (Fernandez and Philipps, 2014), articles on deadly epidemics appeared in almost every media outlet (Bergen, 2014; Branato, 2015; Moore, n.d.; National Geographic Staff, 2014). Similar articles appeared during the H1N1 pandemic (Dominus, 2009; MacKenzie and Marshall, 2009).
Dealing with epidemics: From reliance on God to vaccine development
But the hand of the Lord was heavy upon them of Ashdod, and he destroyed them, and smote them with tumors, even Ashdod and the coasts thereof.
(1 Samuel 5:6)
For thousands of years, epidemics were perceived as a manifestation of divine vengeance – a punishment inflicted by God for sins committed by humans. In the Hebrew Bible, the First Book of Samuel describes how the Philistines, having captured the Ark of the Covenant from the Israelites, suffered an outbreak of “tumors” (Hebrew, ophal), which followed them as they moved the Ark of the Covenant from city to city. Evaluating the events in this ancient story, some modern scholars suggest that the disaster the Philistines suffered could have been an epidemic of some kind, probably a plague (Freemon, 2005; Griffin, 2000). This is reinforced by the unexpected event described later in the chapter – soon after the Philistines return the Ark of the Covenant, the plague ravaged the Israelites, killing many of them, just as it had the Philistines. Yet, the Philistines believed the disease was inflicted by the God of Israel (verses 10–12) – a punishment inflicted by a God mightier than their own for having transgressed against Him. Aware of Israelite history, they recalled the heavy price Pharaoh and his people had paid for their refusal to release the Israelites – they suffered from plague and vermin infestations (Exodus 9:8–15). Thus, they hoped that returning the Ark to its rightful owner would appease God (De Paolo, 2006). Similarly, during the Justinian Plague in 540, the Byzantine historian Procopius of Caesarea blamed the outbreak on the emperor, declaring him either a demon or a sinner punished by God (Horgan, 2014).
This perception of epidemics as inflicted by God as punishment persisted for many centuries, and was believed even by learned physicians (Cunningham, 2008). The only way to counter this “punishment” was to plead for God’s mercy through prayer and fasting (Cunningham, 2008), or to designate scapegoats, such as foreigners, beggars, pilgrims, lepers and especially the Jews (Levack, 1995; Vidal et al., 2007). The search for scapegoats reached its climax during the 14th century, as the Black Death swept across Europe, fomenting anxiety and despair that prevailed, especially in view of the unprecedented scope and magnitude of the plague (Moore, 2007; Nirenberg, 1996). Jews were blamed for deliberately causing the disease by poisoning the wells (Foa, 2000; Levy, 2005). Starting in 1348, many Jewish communities were attacked and their inhabitants massacred or burned alive. Persecution spread across Europe (Foa, 2000). Witches were another group who werre persecuted because they were accused of spreading the plague. Christian (2011) argues that the plague of 1348 was a factor that contributed to the intensity of the witch hunts that occurred between 1550 and 1650.
Nevertheless, in the Middle Ages, a transformation began. The recurrence of the Black Death and the horrific magnitude of the plague led to a feeling of disillusionment with the Church. Thus, the blind acceptance of the plague as a punishment was replaced by a different understanding of epidemics as a part of the natural world, and this allowed for the possibility for human intervention (Dolber, 2010). As time passed and the plague recurred, people shifted from religious means to medical aid for prevention and treatment (Cohn, 2002). Well aware of their own helplessness against the plague, medieval doctors did not completely turn their backs on religion, but rather bridged the divine and the natural, combining faith in God with a variety of earthly treatment regimens. These included, as the French physician and surgeon Guy de Chauliac wrote in his treatise Chirurgia Magna, “pills, to diminish the blood by phlebotomy”; fire “to purify the air”; “theriac” (a medical concoction) “to strengthen the heart”; “fruits and good-smelling things”; fleeing to a non-infected area, and other preventive and treatment measures (Wallis, 2010, p. 421).
In 1348, when the Black Death struck France, King Philip VI commissioned the Faculty of Medicine of Paris to write a report on the plague and make recommendations. The document they wrote offered both a diagnosis and a management plan. Although drawing on astrological explanations – “the conjunction of Mars and Jupiter caused a great pestilence in the air, especially when they come together in a hot, wet sign, as was the case in 1345,” and acknowledging that their work was carried out “with God’s help,” the report reflected a deep faith in the human mind and ability to comprehend and thus control the catastrophe (Wallis, 2010, p. 421). Subsequently, in 1365, John of Burgundy, a French physician, wrote one of the most thorough medical books on the prevention and cure of plague. Burgundy theorized about causes of the plague and explained how to prevent it, incorporating his past experience and faith in God’s help (Zahler, 2009).
Gradually, European governments understood that individual measures alone would not suffice to contain the plague. In Italy, the Great City Council of Ragusa passed a law in 1377 establishing a mandatory isolation period of 30 days for citizens or visitors from plague-endemic areas who sought to enter the city (Stuard, 1992). In time, the isolation period was extended from 30 to 40 days – or from trentino to quarantine – a term derived from the Italian quaranta, meaning “forty” (Mackowiak and Sehdev, 2002; Stuard, 1992), from which the English word “quarantine” is derived. This word is still used to describe the practice of isolating people who have been exposed to a contagious disease to see if they become sick (Mackowiak and Sehdev, 2002). During the following 80 years, similar laws were introduced in Marseilles, Venice, Pisa, and Genoa (Mackowiak & Sehdev, 2002; Matovinovic, 1969). In 1540, when the plague recurred in Vienna, the medical faculty of the city authored a treatise, which “was widely distributed and contained two orders: streets must be cleaned twice weekly, and aromatic wood must be burned in order to improve the air of the city” (Velimirovic and Velimirovic, 1989, p. 817).
In 1546, the Italian doctor, poet, and scholar Giromalo Fracastoro published his theory of contagion, Decontagione et contagiosis morbis et eorum curatione, proposing that epidemics are caused by tiny particles from outside the body – “seeds of disease,” that may be passed on and transmit infection by direct or indirect contact or even from a distance (Nutton, 1990). This emphasis on “seeds of disease” as an explanation for the plague and typhus preceded the microbial theory of diseases by three centuries (Bartlett, 2005).
At about the same time that European doctors were stru...
