In hindsight, it was probably a touch of grad school-induced hubris that led me to assert, in an early draft of my dissertation, that the late twentieth and early twenty-first centuries were marked by chronic disease epidemics.
I based this conclusion on the work of scholars like sociologist Bryan Turner, who in 1987 wrote almost wistfully that the “heroic” treatment of infectious diseases no longer defined medicine, which was now characterized by “mundane medical management of chronic as opposed to acute illness.”1 Similarly, diabetes scholar and nurse Danny Meetoo argued that, although at an international level the focus remains on infectious disease, “evidence of non-communicable diseases reveals an alarming global pandemic and associated fatalities.”2 As a result, according to scholar Ama de-Graft Aikins, nations like Ghana have health systems designed to treat acute infectious diseases, but are “inadequate” to address the rising significance of chronic ailments.3 Epidemiologists may have quibbled over the appropriateness of the term “epidemic” as applied to chronic conditions, but that did not change the fact that issues of chronic illness dominated much of the public health.
But, as we are all aware, in December 2019, an outbreak of pneumonia in Wuhan caught the attention of local health officials and epidemiologists.4 Using human airway epithelial cells, a team of Chinese researchers identified the source of the outbreak as a novel coronavirus, which they named 2019-nCoV. As the virus spread – affecting more than two dozen countries by mid-February 2020 – the World Health Organization dubbed the disease produced by the new virus COVID-19.5 On March 11, 2020, the World Health Organization, led by Ethiopian politician and community health specialist Tedros Adhanom Ghebreyesus, declared the novel coronavirus a pandemic. A few days later, journalist Richard Galant released an essay tellingly titled “This Changes Everything,” in which he wrote, “Everything changed this week. The response to the worldwide spread of the COVID-19 coronavirus upended all of our lives.”
Tedros’s announcement sparked increased advocacy of “social distancing,” also known as “physical distancing,” or the restriction of close interpersonal intimacy.6 Since I study intimacy during nineteenth-century epidemic diseases, COVID-19 forced me to change not only my habits, but also my dissertation’s conclusions. Epidemiologists and historians alike would do well to examine the relationships between past and present disease crises; in fact, many already are. Studying past epidemics, and recognizing the benefits and limitations of historical analogies, can help make sense of contemporary pandemics, on a social if not a biological level. And while the 1918-1919 flu pandemic has clear similarities to COVID-19, even drawing parallels with other diseases that differ profoundly in the ways they spread or the kinds of care they demand, can be productive.
Two centuries before COVID-19, another frightening and novel disease ravaged the Gangetic Plain in northern India and what is now Bangladesh. The disease was known variously as the Asiatic, epidemic, spasmodic, or malignant cholera — or simply cholera. Between 1817 and 1832, physicians and lay observers paid careful attention to the movement of the disease, as well as the kinds of places it gravitated toward geographically.
Of course, cholera remains a horrific disease even to this day. But from the perspective of nineteenth-century observers, it was also an unusual disease compared to previous epidemics. The progressive movement of cholera perplexed physicians; it seemed like the disease could pop up anywhere at any time. Following certain protocols of hygiene, health, and morality could protect one from cholera, but not always reliably so. It could strike whole populations at once, yet sometimes spared entire streets. Some populations seemed particularly vulnerable: poor, “degraded,” “intemperate,” and, above all, Black populations, each group a part of a kind of choleraic underclass.7 And yet, cholera could strike down anyone.
Fear of contagion loomed large in the minds of laypersons like Deborah Norris Logan, a wealthy Philadelphia Quaker. As “Old Dr Martin” attended “with great kindness” to one of Logan’s acquaintances who was sick with cholera, she fretted for the doctor’s health: “I hope he will escape it.”8 However, the College of Physicians of Philadelphia reassured the city’s Board of Health that no “appreciable connexion” had been established “between the full and frequent intercourse of physicians, nurses, attendants, and friends, with the sick of Cholera, and the number of the former who have been attacked with the disease.”9
Intimacy with cholera patients appeared to have no bearing on one’s likelihood of contracting the disease. Not just physicians and nurses, but all those who tended to the sick seemed to be strangely immune to the affliction of those in their charge. A special committee of the Medical Society of Philadelphia reported several instances “where one member of a family has been attacked with cholera and died, while the relatives and friends, who nursed the patient, even occupied the same bed at night, and performed the usual offices to the body after death, have remained free from the disease.”10 Caregivers were not falling ill — or, if they were, it was due to fear, worry, or exhaustion, rather than cholera. In 1832, physicians felt no need to physically distance themselves from their cholera patients, and in fact felt compelled not to. Treating cholera according to the nineteenth-century model of treatment required active, sustained care — continuous rubbing of limbs, periodic bathing of breasts — as well as intimate exposure to patients’ bodily orifices and the fluids they spewed.
What’s Intimacy Got To Do With It?
The parallels between nineteenth-century cholera outbreaks and the 2019-2020 COVID-19 pandemic — to the extent that such parallels even exist — are imperfect at best. For one, the latter disease spread much more quickly, in a matter of months rather than years. On the other hand, cholera killed more quickly; cholera time was measured in hours, not days or weeks. And, although not contagious in the ways that COVID-19 is, cholera killed not one in thirty, but one in three of its symptomatic sufferers.
But the lessons we can glean from studying the history of cholera are no less profound. Physicians and laypersons grappled with the existential crisis that “a quick deciding plague” like cholera heralded, balancing the use of intimate care to treat the disease with carefully maintained distance from what they believed were the sources of the illness.11 Social distancing in the time of COVID-19 might preclude the kinds of physical and sensory proximity that I define as intimate in my work on cholera–such that even my dissertation defense took place virtually–but an understanding of past epidemic disease crises can nevertheless inform how we make sense of and react to such crises today. In the time of cholera, marginalized populations were most at risk from the epidemic. The same holds true today, when Black, poor, and chronically ill Americans are disproportionately vulnerable to COVID-19. As I wrote in a recent article, social distancing was not feasible for poor and institutionalized populations in the 1830s. Similarly, the intimacy that allows COVID-19 to spread is not optional for marginalized people.
Nineteenth-century caregivers responded to cholera epidemics by ratcheting up the physical and sensory proximity between themselves and their patients in order to better understand the disease at hand – but, then again, they were more or less unanimous in their deductions that cholera was not contagious. In the age of COVID-19, that very same physical and sensory proximity — though it might alleviate some of the emotional toll of social distancing and refine our understanding of the pandemic — can spread disease among the populations most vulnerable to it.
- Bryan S. Turner, Medical Power and Social Knowledge (London: Sage, 1987), 8. Return to text.
- Danny Meetoo, “Chronic Diseases: The Silent Global Epidemic,” British Journal of Nursing 17, no. 21 (Dec. 2008): 1320. Return to text.
- Ama de-Graft Aikins, “Ghana’s Neglected Chronic Disease Epidemic: A Developmental Challenge,” Ghana Medical Journal 41, no. 4 (Dec. 2007): 154 Return to text.
- Na Zhu, Dingyu Zhang, Wenling Wang, Xingwang Li, Bo Yang, et al., “A Novel Coronavirus from Patients with Pneumonia in China, 2019,” New England Journal of Medicine 382, no. 8 (Feb. 2020): 727. Return to text.
- Zhe Xu, Lei Shi, Yijin Wang, et al., “Pathological Findings of COVID-19 Associated with Acute Respiratory Distress Syndrome,” Lancet Respiratory Medicine (Feb. 18, 2020): 1. Return to text.
- See A. Wilder-Smith and D. O. Freedman, “Isolation, Quarantine, Social Distancing and Community Containment: Pivotal Role for Old-Style Public Health Measures in the Novel Coronavirus (2019-n-CoV) Outbreak,” Journal of Travel Medicine (Feb. 13, 2020): 1-4. On March 25, 2020, Ohio governor Mike DeWine tweeted: “We hope everyone is back in business shortly, but we don’t think this [COVID-19] will peak until May 1. The only way we slow it down is with physical/social distancing.” See Mike DeWine, Twitter post, March 25, 2020, 2:48 p.m., https://twitter.com/GovMikeDeWine. Return to text.
- The term “choleraic underclass” is a nod to Sean Strub’s concept of a “viral underclass” created by discriminatory policies in response to the HIV/AIDS crisis. See Sean Strub, “Prevention vs. Prosecution: Creating a Viral Underclass.” Poz, 18 (Oct. 2011), https://www.poz.com/blog/prevention-vs-prosec Return to text.
- Diary of Deborah Norris Logan, vol. 14 (Mar 1, 1832 – Jan. 26, 1834), Aug 30, 1832, Logan Family Papers 1664–1871, Collection #379, vol. 41, Historical Society of Pennsylvania. Return to text.
- Report of the College of Physicians of Philadelphia, to the Board of Health, on Epidemic Cholera (Philadelphia: DeSilver, 1832), 31. Return to text.
- Report of the Committee of the Medical Society of Philadelphia on Epidemic Cholera (Philadelphia: Lydia R. Bailey, 1832), 12. Return to text.
- Diary of Deborah Norris Logan, Sep. 4, 1832. Return to text.