In Italy and France during the 17th century, the plague doctor was a physician who treated victims of the bubonic plague. He would dawn a plague mask which usually resembled the face of a white bird to include a curved beak and glass, goggle-like eye holes. Inside the beak or nose-case were placed various aromas—often lavender—and the two holes under the beak allowed the doctor to take in air which was believed to be purified thus protecting him. The widely-held belief at this time was that the plague was transmitted through smells caused by a miasma (μίασμα, ancient Greek for “pollution”), a noxious form of “bad air.” This was the dominant medical theory of contagion transmission that persisted at the time until the late 19th century when germ theory came into prominence and adopted by the scientific community. Attributed to Charles de Lorme, the chief physician of Louis XIII, the plague mask became a symbol of impending death, of fear and in years long after the plague, a symbol used during carnival, especially that of Venice.
During the outbreak of the bubonic plague in Italy in the 1650s, it was believed that the doctors taking care of the sick would dawn these masks in addition to long garb and wide-brimmed leather hats. Even though the Black Death of the 14th century is estimated to have killed over a million people in Italy, it was the the plague epidemic between 1656 and 1658 which killed 145,000 people in Roma and 300,000 in Naples among many others such as the 1630 plague in Milan. And amidst the use of plague doctors came unscrupulous business and medical practices such as charging more for fake cures even if the main purpose of these doctors is today widely understood as their having been the agents of demographic information collection.
While it is widely debated among historians if this costume was in fact used frequently by plague doctors, according to historian Winston Black it is doubtful that de Lorme was the inventor of this mask. Despite the fact that most all of the pictures and writings we have today of this costume are largely satirical, the imagery of impending death represented by these masks resonates through the present era. Because of this calamitous imagery together with the Coronavirus outbreak having put an end to Venice’s carnival celebrations last month, it is inevitable that those of us in Italy are haunted by the figure of the plague doctor. What is it about this figure that so haunts the present amidst a virus that thus far is far less deadly tha the plague?
Last month a government directive for most of northern Italy specified that in addition to schools and universities closing there were to be no outdoor festivals, markets, or public and private gatherings. I took this order to heart and immediately took care of my children while edging in time to get work done. Two days later, I found our car towed since the weekly market in town which takes place along our street went ahead as planned. It was then that I also learned that the football pitches in our town and every other town nearby were filled with boys and men playing contact sports all day long. Many calls later to my local council and I would learn the stark difference between that which was written as law and that which exists in practice. These early observation left me unsurprised that the Coronavirus cases steadily rose in Italy.
Now almost three weeks later after everyone in northern Italy has moved from self-isolation with the entire country now in a full-on quarantine, not even the best high tech apps or home security solutions can stop what the medieval world assumed would come for them. While the plague doctor is a figure from the past symbolized through Venetian masks, in many ways new technology has served as its contemporary medical surrogate. While many believe that new tech might save us from this virus as AI (artificial intelligence) is used in population-screening and robots throughout China are minimizing the risk of cross-infection in hospitals, the biggest benefit of new technology will likely be its ability to assist us with our mental health. While millions in Italy are undergoing social isolation, new tech can divert us away from the reality of being shut off from the outside world, locked indoors for what will be at the very least six weeks. As much as I have been critical of our overuse of social media, these spaces might be the very tools that help to pave over the psychological rough patches when human contact might actually have to come in the form of a social media thumbs up. I do wonder if the internet might be a more effective—albeit postmodern—plague doctor in this hour of horror.
While the mortality rates do not nearly approximate those of the 17th century plague, the rates of infection are astonishingly high with a recent analysis of infections from Singapore and Tianjin in China revealing that two-thirds and three-quarters of people respectively have caught Coronavirus from others who were incubating the virus while themselves remained asymptomatic. Unlike the Black Death where the body was visibly sick, Coronavirus means that most everyone in Italy lives in fear of both the healthy and unhealthy body—everyone is suspect, from that individual who might sneeze as a result of an allergy to the perfectly healthy-looking person walking down the sidewalk. With shops and bars ordered to close for two weeks as Italy tightens its nationwide quarantine, the world has suddenly moved from that of a frivolous life of social media and hashtags to that of estimating the best time of day to go out for groceries in order to avoid others.
Meanwhile in the world of clinical research, we have learned many lessons from attempts to get a universal flu vaccine off the ground with the Gates Foundation announcing last year that they are nowhere near the benchmarks they initially set. Director of the pneumonia program at the Gates Foundation, Keith Klugman, stated, “There is literally nothing at the moment close enough that we saw that we thought we could pursue.” The history and evolution of the influenza control tells this story quite well as any scientist will tell you that nobody can predict when the next outbreak will occur. As viruses replicate they do not proofread their RNA genome which means that they will always mutate and this is why finding a vaccine to the flu is such a challenge despite the recurring mutations of influenza strains having prompted the introduction of a quadrivalent inactivated vaccine. (For an excellent history on influenza and vaccine development read this article by Barberis, Myles, Ault, Bragazzi and Martini.)
Viruses are unpredictable and largely uncontrollable through medicine in their early phases, but the one common denominator between most contagions is how to mitigate them. Even for a disease epidemiologically vastly different from COVID-19 such as the flu, we know with certainty that social distancing is the one sure way to mitigate the spread of this disease. Other historical cases of epidemics tell a similar tale such as the 1918 flu pandemic (also known as the Spanish Flu) which killed as many as100 million people worldwide. There were two notable reactions to this epidemic which demonstrate that in the absence of medicine containment is the next best defense. When examining how Philadelphia and St. Louis approached the Spanish Flu, the mortality rates differed vastly because of how St. Louis employed social distancing measures within two days of the first case. Philadelphia, on the other hand, took 16 days to implement social distancing which resulted that city having over twice the mortality rate of St. Louis. The goal of governments today in handling epidemics such as Coronavirus is to flatten the curve in order to mitigate the spread of infection as early as possible.
Invariably in the initial weeks of government-mandated isolation, I keep thinking about the fact that while I was working at home taking care of two young children, careful to stay inside, men and boys were outside playing football in the parks. Now that the Italian government has finally gotten it right, we will have to be patient to see the results of our collective efforts as we wait and hope for the curve to flatten.
Where the masks of looming death once worn by plague doctors are far from this eery present as people are now locked up inside their homes panic-stricken to go outside and ever more frightened for their parents and children, we are living in a situation where the contagion is passed from one seemingly healthy body to the next. Everyone is suspect and there is no plague doctor simply because we are woefully aware that there is no “cure.” Not now at any rate. And the price we must pay, as if we were all bees in a large hive called earth, is that we must now swiftly respond cooperatively and humanely with one another.
Here in Italy we are living in a human experiment—the first of its kind—where an entire nation is locked down completely. More ironically, after weeks hearing the xenophobic comments made about the Chinese and refusal of Italians to eat in Chinese restaurants, the sentiment has finally boomeranged back at Italians. Graphics on news sites show in big black arrows overlaid onto a red map the spread of Coronavirus from Italy to other countries to include Nigeria while other sarcastically suggest that every boycott Italian restaurants. With Trump’s announcement of a travel ban from the EU today, Italians are seeing how being pigeonholed as the source of a plague translates most unkindly when the shoe is firmly placed on the other foot.
There are lessons to be learned within the coming weeks from public health to medicine to human interactions. Let’s hope that we can cooperate with one another in order to keep the hive alive.