The history of COVID-19 and the past pandemics: interviewing Professor Bernardino Fantini

Bernardino Fantini, Professor Emeritus of History of Medicine and Health, University of Geneva

MGM: Prof. Fantini are you a historian of science and medicine? We have already heard several historians and philosophers who have framed the pandemic and the various pestilences as dark periods that were followed by rebirths…economic recoveries. However, no entry of “historian of science until now”. You are the first. In the past, what scientific and medical lessons have been learned from pandemics? 

BF: The impact of a pandemic crisis is always very strong and affects the entire population. Social relations, family relationships, the daily life of each person is strongly affected. As we read in all literary accounts, from the plague of Athens described by Thucydides to the Plague of Albert Camus, As a result, public authorities and the various professions and skills regularly react. People react emotionally, with opposing reactions, from anguish and disgust at others to empathy and solidarity. And you try to understand the causes of events and find remedies. An epidemic crisis is also the time when many certainties are put to the test, with the emergence of new attitudes, some irrational, others based on reflection and knowledge.

– In the event of an epidemic crisis, the medical community mobilized or was directly involved by the authorities, even though, in the absence of adequate conceptual and technical tools, it was not possible to find effective remedies. They tried to understand the nature of the disease and its causes. Clinical observations were interpreted on the basis of available knowledge, and physicians were generally able to distinguish diseases from one another and understand their novelty, if it was an emerging disease. This always resulted in a broadening of available knowledge, reflected in medical treatises and changes in practices. 

– Some examples. On the occasion of successive plague pandemics, especially starting with the terrible Black Death of the late 14th century, a very large number of books were published, many simply chronicling the ‘pestilence’, others with various attempts to explain the causes and modes of disease spread. A particular genre was constituted by the Consilia contra pestem, containing the most varied suggestions to avoid contagion and the sanitary rules to be followed to prevent it. In many cases the advice found in these texts had a solid empirical basis, even if before the pastoral revolution of the late nineteenth century the causes were not known and therefore there was no solid scientific basis for such advice. Thus, the making of the famous ‘plague doctor’s outfit’, which has now become just a carnival mask, although based on flawed scientific theories (the ‘theory of miasms and bad smells) had a number of components that resulted from experience and allowed the isolation of the doctor from the sick person and the maintenance of ‘social distance’.

– At the time of the arrival of the great syphilis pandemic after the discovery of America, Fracastoro published his famous treatise on this disease, which provoked a great debate on ‘living contagion’. In the eighteenth century, the rinderpest pandemic in northern Italy gave rise to a great deal of research and publications, which greatly advanced knowledge about contagions and ways to prevent them.

– Smallpox in the eighteenth century made real carnage (for some epidemics the disease killed almost half of the children) and this led the scientific community to debate the usefulness of preventive measures, in particular first variolisation and then vaccination, after Jenner’s discovery in 1796. Mathematicians and physicians confront each other on the statistical study of the effectiveness of the remedies, whose results will then be the basis of compulsory vaccination measures in many countries. 

– In the nineteenth century, the dominant epidemics are cholera and tuberculosis. All medical academies organize missions to understand the nature of cholera and the ways in which it spreads. Scientific laboratories are mobilized to search for the causes of these diseases, the germ theory is born and culminates in the research of Pasteur and Koch. In 1854 Filippo Pacini isolates the vibrio of cholera and this discovery will be confirmed thirty years later by Robert Koch, who also isolates the bacterium responsible for tuberculosis. Science now makes it possible to follow the causes of contagious diseases in the laboratory and in the field, giving rise to current preventive and curative practices, vaccination, serotherapy, antisepsis, drugs. Hygiene finally becomes ‘scientific’, that is, based on the experimental study of the causes of disease. 

MGM: Cooperation in vaccine development is perhaps the key element for the defeat of SARS-Cov2… but we also know that there is a lot of competition between manufacturers, when in this case there is even a problem in keeping up with the production needed for the whole world, “A totally unsaturated market”. It is what is metaphorically called a Blue Ocean, where there is room for everyone and not a Red Ocean where the competition is massacring and indicates in jargon “a saturated market”. Can you tell us about great collaborations and useless competitions in the centuries of history of medical science and if possible with reference to pandemics and plagues?

BF:  It can first be noted that the first coronavirus pandemic, SARS in 2003, was quickly confined and then halted in a matter of months thanks to the rapid detection of the virus and the application of isolation and tracking measures. But at the same time, it was the first time the Internet was used at the health care level to share clinical, epidemiological, and virological data, with exemplary international collaboration.

– A vaccination strategy depends on two key elements, the discovery and development of the vaccine and its large-scale production and dissemination. The first element is necessarily based on competition between research centers, while the second must necessarily be based on cooperation between production and dissemination centers. In order to be able to produce enough vaccines to vaccinate entire populations, it is necessary to enlarge the production base, localizing the production facilities in the various countries. In addition, an efficient healthcare system is needed throughout the country, which must be able to count on collaboration at all levels of society.

– In the past and until the nineteenth century we cannot talk about scientific collaboration, because each state, each city closed its borders and often obscured the dissemination of medical and epidemiological news, so as not to alarm the population. Foreigners were seen as potential sources of contagion and were therefore excluded. Only the scientific academies continued to exchange publications and discoveries, but each academy organized studies and scientific missions autonomously.

– International health collaboration began in 1858 with the first international health conference in Paris, a direct result of the first two cholera pandemics. The purpose of these conferences, at a time of developing industrialization and international trade, was to discuss quarantine measures to minimize barriers to trade. However, but hand in hand with these conferences there is a growing awareness that only a true international collaboration can lead to effectiveness in controlling the spread of epidemics, since germs do not know borders. This will later lead to the origin, immediately after the Second World War, of the World Health Organization.

– Collaboration among physicians develops, albeit slowly, whenever a therapeutic or scientific innovation shows great validity. Thus, the importation of cinchona bark from South America gave rise to a great diffusion of this drug, very effective against “intermittent fevers” (malaria), and in the various universities there was a long discussion on how to use it (for example, the famous diatribe between Bernardino Ramazzini and Francesco Torti on the effectiveness of quinine). 

– Very interesting is the case of vaccination against smallpox, characterized by the need to distribute Jenner’s original vaccine (the only one actually effective, for reasons that have been clarified only a few decades ago). Thus, Jenner’s vaccine travels throughout Europe, arrives in Asia and the USA. Even if two countries are at war (as is the case with France and England), the vaccine is passed through neutral countries, such as Switzerland, to be made available.

– In the nineteenth century begins the organization of the great international medical congresses, which allow the exchange of knowledge and techniques. After the Pastorian revolution, the spread of new knowledge is rapid, thanks to scientific exchanges. Lister in England introduced antisepsis, even the faraway Japan created a scientific laboratory directed by a student of Robert Koch, who visited it in 1908.

– MGM: … The primary pandemic is called SARS- COV2 but the secondary is called anxiety depressive disorder. That’s what the psychiatry and mental health societies are continually bringing into the common debate about: did this focus on the mind, in ancient times exist? Or was it about the soul and very often the pandemic was placed in a religious context?

BF: Even if in the contemporary western world religiosity seems to play a minor role, throughout the history of humanity religion, in its various forms, has always played a central role in the interpretation of life, illness and death. Epidemics have almost always been considered as divine punishments for the bad behavior of individuals and populations. Prayer, religious ceremonies, processions were organized to ask for the protection of the divinity, even if this resulted in an increase of contagion. 

– In ancient times and at least until the nineteenth century, there is no separation between mind and body. In classical medicine, dominated by the humoral theory, the balance between the humors or their “dyscrasia” is at the same time cause of health and physical and mental illness. Of also the famous motto ‘anima sana in corpore sano’. The mind is ‘in’ the body, one cannot exist without the other. The mind can only be in the body and everything must be done to allow both poles of the dichotomy to function properly. The two elements can only be ‘healthy’ together.

– Throughout the centuries the pendulum has swung between the two poles of the dichotomy, shifting from time to time the emphasis on the mind or the body. Like all fundamental dichotomies (think of life/death), this one is unsolvable, because, like a magnet, one pole does not exist without the other, at least in the earthly life of organisms.  Paying the price of simplifications certainly excessive, we can identify in the cultural and social history of the Western world important shifts towards one end or the other of the pendulum of mind-body relationships, even deep changes that cause anthropological revolutions and change the dominant ideologies.

– With the origin of Christianity and then the Muslim world, the mens is replaced by the soul, which has a divine origin and is separated from the body (and throughout the Middle Ages there was a debate about when the soul enters the body, forming a conscious and divine individual, usually three months or four after conception). Christian theology takes up the Platonic philosophy that considered the psyche (ψυχή, in Greek), the soul, as distinct from the body, even if later the point of reference will be Aristotle, for whom the soul is not distinct from the body, but coincides with its form, represents the ability to realize the vital potential of the body. In religious practice as well as in general culture, the body is often seen as a sort of prison, a place of animal passions, from which one must free oneself, even with corporal punishment. In the Middle Ages and even later, in various cultural environments, the exercises are not physical, but spiritual and there is a tendency to asceticism, which means to move away from the body, to remove the ties with the material world represented by the body. Ecstasy (from the greek ἔκστασις, composed of ἐξ + στάσις, ex-stasis, “being out”), celebrated in the lives of the saints, or trance (from the Latin transire, to pass), studied by cultural anthropologists, are a psychic state of suspension and mystical elevation of the mind, which is perceived as estranged from the body: hence its etymology, indicating a “coming out of oneself”.

– At the end of the Middle Ages, it is probably the ‘black plague’ that pushes to re-evaluate the body, which falls ill and dies, thus destroying also the mind. With Humanism and the Renaissance, the classical myth of beauty, of body and soul, resurfaced, and the classical idea of health as harmony and balance between body and mind returned. Since the early twentieth century, in the post-modern world is the body that dominates the collective imagination, the female or male body well formed, lean, muscular and harmonious, without ‘deficits’ and even enhanced, as for the movement of transhumanism, which speaks of replacement and improvement with biotechnology organs, including the brain, leaving in obscurity and in the background the improvement and enhancement of the mind. In recent decades, the anthropological transition has further strengthened, resulting in a majority though not yet dominant ideology centered on corporality. Cultural activities, ‘spiritual exercises’ are being replaced by physical exercises. And to this is added the extreme attention to food, to cooking, to healthy eating for the well-being of the body. Even in building a proper response to the current pandemic, and especially in preparing for the future when this is all over, redefining a proper balance between mind and body, between culture and physical activity could be a non-secondary goal.

MGM: Who was funding health in the days of past plagues and pandemics? Was there a micro-system of welfare or charity, or did the rich come out protected compared to the poor? And how was scientific research financed in those days?

BF: It is necessary to distinguish between the treatment of the sick and the practice of healthcare for the whole community. The former were reserved for those who could pay the doctor, even if there were ‘holy doctors’ who also treated the poor. Health care practices have always been the responsibility of civil authorities. According to the theories of the time, contagion was fought with quarantines and cordons sanitaire and with the systematic cleaning of cities, all activities necessarily taken over by the political power, which also had the economic and human means to enforce sanitary measures. Assistance to the sick took place at home for the wealthy and in hospitals, mostly run by religious confraternities, for the poor.

– From the eighteenth century, for social reasons (the population crisis, the agricultural and industrial revolution) and cultural reasons (the century of Enlightenment, reforms and revolutions) medicine and other health professions broaden their field of action, not being interested only in individual patients, but beginning to feel a responsibility towards society as a whole. Governments create ‘health police’ structures. If classical hygiene aimed at controlling and modifying individual behavior, modern hygiene becomes public, addresses the community and is necessarily carried out by the community, through public health regulations and legislation.

– Inequalities in the face of disease and death are a constant in the history of epidemics. Even if germs do not distinguish between rich and poor, powerful and simple citizens, as many chronicles and frescoes tell, in practice the rich could better protect themselves and eventually move away from a city hit by pestilence. Moreover, the rich had the possibility to feed themselves sufficiently, which allowed them to better resist infections. The ‘right to health’, as a fundamental right of every person, without distinction of sex, religion or social position has been recognized only in the second half of the twentieth century.

– Scientific research in the modern sense, with laboratories and research groups, is a novelty of the nineteenth century and especially of the twentieth century, with the development of so-called ‘big science’. It took place mainly in universities, public and private, and in the laboratories of industries, especially the chemical and pharmaceutical industries. Previously, innovations in the medical field were the result of the craft laboratories of doctors and naturalists or the discovery of natural medicines by explorers, as was the case of quinine for the fight against malaria. In the nineteenth century, ‘scientific medicine’ developed and the principle that all therapeutic measures, starting with drugs, must be based on scientific knowledge and laboratory verification of the efficacy and safety of the treatment was established. 

– MGM: What is new about SARS-Covid19 vaccines compared to those previous?

BF: Although several vaccines use traditional technologies, with attenuated or killed viral forms, the Pfizer and Moderna vaccines are based on the use of mRNA. Basically, what is introduced with the inoculation is a message, an information, a messenger that tells the ‘cellular machine’ of our body to produce a virus protein, to which the immune system reacts recognizing it as foreign. This is what has greatly accelerated the research of the vaccine and allows its great validity even in case of virus mutations. In fact, it will be enough to change one ‘word’ of the message for the vaccine to cause the production of the mutated protein. This is the first large-scale application of the theoretical and philosophical revolution produced by molecular biology, which defines life as a message that is transmitted through generations, changing with evolution, and that controls the chemical and physical processes necessary for development and vital functions.

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