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November 10, 2009

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VIEWS: NEWMAN'S PANDEMICS

Pandemic Revisited

[Sep 6 07]

The great flu pandemic of 2007 hasn’t happened yet. But don’t go away! The pandemic flu knows no seasons, and isn’t a once-a-year event. Bird flu is spreading – mostly among birds so far, and in many places. What we don’t know about it would fill volumes: we never know enough beforehand. That seems to be a law of nature. Grim scenarios might still happen.

I wrote: “Ethics and Triage – A Nasty Scenario” a few months ago, suggesting that even with the best of pandemic planning, our health care systems might become overwhelmed if one or more of the basic assumptions proves too optimistic. I received feedback suggesting that our propensity to go into ‘feeding’ frenzies when confronted with real or anticipated scarcities of anything – such as popularized toys or almost anything else – makes it inevitable that the ‘nasty’ scenarios, including riots and mayhem, are highly likely. In other words, the breakdown of civilized norms will surely accompany pandemic. My good friend Thomas Hobbes has described life in such circumstances as “nasty, brutish, and short.”

Such frenzies could happen, and might happen here and there. However, the records of what happened in the London Plague of 1664-65 and what has happened since in times of war, pandemic, and disasters both natural and deliberate, including ice-storms, floods, hurricanes, earthquakes and tornados, suggest that we humans are amazingly resilient and will as a rule help each other. The folks who make up the ‘grass-roots’ in our communities, though usually ignored by the planners, are our great strength.

Planning can help. Preparation, including training and education, can help greatly. First Responders are mightily needed. Central governments can play a key role in organizing supplies and logistics, and bringing in emergency legislation such as quarantines. But as we have seen time and again, it’s the folks on the ground where and when ‘it’ happens, who must do the coping.

The professionals can seldom get to the scene (or many scenes simultaneously) immediately. Sometimes it can take hours, days, and even weeks to get through the debris. Too often, the jurisdictional barriers are worse than the physical ones. Until the professionals arrive, people suffer and die without recourse other than helping themselves, and helping those around them. Sometimes, as in a pandemic, too many will suffer and die; regardless of what we do. But we must do what we can while we can.

The more distant the authority, the longer the delay: the more immediate to the disaster, the quicker the response. Centralization has no place in disaster first response. Its main utility is in churning out press releases justifying its existence.

We organize for disasters ass-forward and upside down.
 

Danger Pay

[Aug 27 07]

Back when SARS threatened Toronto, the Ontario government of the day introduced strict quarantine measures reminiscent of the often drastic quarantine laws applied in times of plague -- [as in London 1664-65].

Quarantines are difficult to enforce, but the quarantine worked for Toronto and SARS was contained. But, as can happen when something new attacks in epidemic proportions, people died and some of them were healthcare workers.

They died in part because we didn't know enough -- we never do -- and in part because people wore the wrong masks, or they weren't properly fitted, and because the hospital culture took a while to get over an under-estimation of the dangers. We will be ready for SARS next time, but next time it won't be SARS, and there will be casualties.

One outcome of the re-hash of the SARS experience is a call for danger pay -- looking ahead to an anticipated pandemic. Undoubtedly healthcare workers will face risks and uncertainties; some will be casualties and some will die. It's not enough to say that it goes with the territory and the Hippocratic Oath -- I'm not sure it does when it comes to the crunch.

In the exceptionally virulent plague outbreak in London [1664-65], many of the best doctors and nurses died in the first weeks, as they worked valiantly and desperately to help the sufferers. This was not the dark ages; London was a capitol of enlightenment, home to many men and women of science and medicine. But when the plague came, in a particularly horrific form, they didn't know enough. Regardless of how advanced we think we are today, the same truth holds -- we never know enough, and too often, the best among us die trying to stem the tide.

Danger pay or compensation or insurance may well be justified. But think about it: pandemic is just one form of disaster affecting the many, and the response to disaster involves the many. There are many unsung heroes. There are many who suffer, and too many who die. Pandemics, like disasters in general, do not differentiate between the professionals and the rest of us. Doctors and nurses, and orderlies, and many other healthcare workers, are on the firing line. But so too are the paramedics, firefighter first responders and a host of others including volunteers. And then there are the collectors of the dead, and the ones who dig the pits and dispose of the corpses. How about the folks trying to maintain law and order while the world around panics and goes ballistic? And finally, there is the largest category of them all: you, me, and everyone else; the patients and the potential victims. We are all in it together, so where does danger 'pay' begin and end, and with whom?

A few callous souls have argued that if 'we' don't get danger pay 'we' will simply down tools and refuse to show up at work; the 'we' variously referring to doctors and other healthcare workers. It's an interesting argument. Fortunately, there is a precedent --

A few years ago, emergency room doctors in Winnipeg walked out. They claimed, likely justifiably, that they were overloaded, the system was breaking down, and no one cared. So they downed tools and the entire emergency system shut down. I think the walkout lasted for two weeks or thereabouts. The mortality rate in Winnipeg dropped alarmingly; of the order of 30 percent. In due course, the emergency people returned to work.

But one seems to have absorbed the underlying issue: if there were no healthcare system, would we be worse off or better off? What would happen if all the patients downed tools and walked out? How would the politicians cope with a pandemic of angry voters? Let them try to quarantine that!

Remember Bob: "You have the power." So vote as you like, but vote often.

Ethics and Triage: A Nasty Scenario

[Dec 12 06]

If only the rich could pay the poor to die instead of them, Then the poor would make a very good living. (Ancient Yiddish Joke)

A Flu Pandemic has begun. The hospitals are crowded. Staff is overworked: many have come down with the flu – one sort or another. The ‘normal’ flu doesn’t vanish just because of a pandemic. Even before the flu's came, the usual ailments and conditions have just about taxed the limits of the system’s capacities; and the pandemic is a long way from peaking.

It’s bitter cold outside. People, old and young, are dragging themselves, or loved ones, or neighbors, to Family Practice offices, and to hospital Emergencies. Taxis refuse to take them – this stuff is dangerous! – public transit is barely operating: drivers are sick, or calling in sick and maintenance is non-existent. Who would want to ride the bus and breathe in undiluted virus? So people drive, or walk, or stumble, or are wheeled to their local version of purgatory.

The paramedics and first-response people, like many doctors, nurses, and orderlies, have, in some cases, literally worked themselves to death. Others are genuinely seriously ill at home. In any case, hospitals won’t allow ambulances to unload: the situation has become too serious for ambulances: they are irrelevant against the scale of the emergency. This puts the First Responders in a Catch-22 bind: what are they supposed to do with the living, the dying, and the corpses? The fire-paramedic and police stations have become hospital wards, and mortuaries.

Family Practice offices are crowded; there weren’t enough to begin with, and now more and more are closed – the doctors and nurse practitioners have strived valiantly for weeks, working round the clock; but many have succumbed to the illness and are too sick to carry on. Some have already died. The sufferers keep arriving – and are told to go to “Emergency.”

The Emergency is so crowded it’s impossible to move: too few staff, too few Triage Officers’, too many forms and too few to fill them in. More tests needed? – long waits; supplies dwindling.

It’s not just in “Emergency” – the corridors are lined with sick and dying. The ‘lucky’ ones have beds; others are wrapped in blankets on the floor. The sound of coughing, hacking, groans rasps and rattles adds to the background. The place doesn’t smell- it reeks.

The only ones around to help are family and volunteers; but they too are a dying breed.
The kitchens have shut down. The Tim Hortons a few blocks away is the main source of hot soup and beverages.

The chaos extends outside the hospital. Every few minutes a car pulls up to the curb and someone terribly sick is pushed out or loaded into a wheelchair; and then abandoned. People are desperate. People don’t want to watch loved ones die. They want to get them to where help is available, but there is no more room at the inn.

There’s no room and the authorities have instituted a quarantine. There are fierce barriers to admission - -even to approaching the hospital. Police and Military, guns evident, are supposed to enforce the ban, but they didn’t sign up to turn away the sick and dying to perish of exposure on the street; at the very gates of supposed aid and comfort. They try to keep a semblance of order: lining up the wheelchairs – many with their frozen dead occupants -- in neat rows. Some are in tears; none will ever be free again in their minds. This is not a job: this is hell.

Worse yet are the ones who have lost it, watching their loved ones going downhill with no access and no hope. Some arrive in a rage, screaming threats, demanding access -- armed and very dangerous. Are they to be gunned down on the spot? Is there time, patience, and skills to talk them into calm? Can it be done?

Pharmacists (legitimately part of the Front Line) are also besieged as people line up to request, demand, and plead for something – anything – to help their loved ones. They are worked off their feet doing what they can, but they are hampered by government irresolution in deciding what powers pharmacists should have. It would have been an enormous assist to everyone if government had given them emergency powers to prescribe and dispense on the spot; and if government had also picked up the tab for all pandemic-related drugs. Some go ahead and prescribe anyhow; but supplies are dwindling.

As in all pandemics, even in our supposedly enlightened age, the miracle-workers with trumped up testimonials from the crowned heads of Europe, quacks with nostrums, and ‘end is nigh’ callers to repentance all have their moments of glory -- and riches: its remarkable how expensive the goods and services are which these selfless folks ‘freely’ offer. Human nature is eternal in its often excellent ways -- and in its folly.

At the other end of the chain, the mortality rate among those admitted to hospital is much higher than predicted: in part because the virus is especially virulent; in part because the system has broken down; and in part because all attempts to establish interior quarantines (cohorting) have been defeated by increasingly over-worked staff, and a shared air-circulation system. The usual crop of hospital-specific infections is proliferating.

There are no more resources left and little chance of getting any anytime soon: suppliers and distributors are at their limits and manufacturers are forced to ration dwindling output.

The hospital mortuaries are full. Autopsies will have to come later -- much later; if at all. Meanwhile, bodies, neatly toe-tagged, are stacked like firewood in a more-or-less exterior courtyard. The weather is cold enough: they will wait there quietly. Anyhow, morticians have closed up shop for the duration. Those with the courage and strength retrieve their dead and go to join the long lines at the crematoria.

The death rate is also high among the thousands cleared out from the hospitals to make room for the pandemic flu sufferers: sent home, or to long-term care facilities, or otherwise moved out of sight and out of mind. They live, or die, or will be debilitated for the rest of their lives.

Scalpers are thriving: they don’t mind the cold as they wait patiently on the streets around the hospitals for new arrivals. The going rate for an admission for one is $25,000 (up front in cash). There are enough takers to make the middle-men wealthy, and to handsomely reward the good folks inside who are ready to pocket the bribes. Being a triage officer, or a key person in the paperwork chain, is a license to print money.

Anyhow, a disproportionate number of highly placed bureaucrats and politicians, and their friends, family, and lovers, seem to get rooms and beds and ventilators, and the world’s gone mad around you, so why not get some benefit? After all, you’re one of the few still on the job, taking the big risk with your life, so why not?

There are still some who are trying hard to stay ethical – to do the right thing because it’s in their nature. But it is hard; because so much has gone wrong and it’s not a matter of pointing blame. It doesn’t mean the Plan was flawed. It doesn’t mean that society, and the system, were at fault. There may have been flaws and errors, but that’s only because we are human and frail and mortal and come with the full set of emotions. This emergency is overwhelming – like a millennium storm it has surged through our cities and buried our best plans and hopes in an abyss of tragedy. (It happens).

PostScript

Worst Case scenarios seldom happen: by definition, they are unlikely. But when they do happen, they tend to be much worse than anyone could imagine.

I wrote this scenario to try to answer a lurking question: are Ethics and Triage at all compatible? Worst Case scenarios test the limits and when I think about what could happen at the limit, I don’t at this point see any room for Ethics (or Morality) in a Triage situation --- unless, and this may be key – the Ethics are built in to the Triage Design.

However, stating a set of lofty humanitarian principles up front is not the same as ensuring they are followed in the field. With the best will in the world, Triage has to be based on other principles – such as making the most effective use of limited resources, and the greatest good for the most.

Fairness is a worthy test of a system – in the sense that Triage and what follows must not be arbitrary, and should be equitable (without fear or favor). In the main, that is feasible – though there will always be queue-jumpers. But Fairness has little to do with Compassion.

Hard choices -- sometimes the trade-offs are wrenching, at best.

I’ll try to work some more with these issues. Your views, in the light of your own experiences, would help.

Be well.

Pandemic Flu Planning: "A Flow is a Quantification of Assumptions"

[Dec 6 06]--References. I have made use of three references: 1] Government of Ontario Flu Pandemic Plan, Chapter 17 Acute Care Services & 17a: Tools; 2] Shoppers Drug Mart Healthwatch Pamphlet: Flu; and 3] Government of Ontario Pamphlet, “What you should know about a flu pandemic.”  April 2006.

It is spread mainly by virus in the air.

Drugs used to treat ordinary flu may also help people with pandemic flu but we may not have a large enough supply, and we won’t know how effective they are until the virus is identified.

ASSUMPTIONS

Inclusion Criteria

Identifies those needing a level of resources which cannot be met in a pandemic, and even if ICU resources were found they would have a very poor chance of survival (SOFA Score of > 11 i.e. mortality rate of > 90% even with full critical care). For example --

“No pandemic care for elderly” as the page 1 lead-in to an article by Joanna Frketich.

On page 8 of the same issue, an article by Peter Van Harten was headed”

“Pandemic rules hard to swallow?” with the sub-head “MD predicts major ethical debate.”

Be well.

The London Plague of 1664-65: Summary [from a 2006 columnn]

Foreword

The following account is based on Daniel Defoe’s famous “A Journal of the Plague Year.” He wrote it in 1722 -- the result of interviews with survivors and extensive research into parish records, brought together by a remarkable novelist and investigative reporter (in the true sense).

The Arrival of the Plague

The plague had visited 60 years before, and a few times each century for centuries before that, but with the exception of the terrible “Black Plague” of the 13th century, each visitation was no worse than those of the other scourges – flu, smallpox, and starvation.
There was no reason to expect anything different.

When the plague reached London it wasn’t a surprise; it had been reported in Amsterdam and elsewhere on the Continent. It moved slowly from town to town.

There were 3 plague deaths from late December 1664 through January 1665; they were all in the same house where visitors from the ‘Continent’ were staying. A fourth death was registered in early February: this time in another house in the same parish.

The winter was long and bitter cold and this seemed to inhibit the infection. Then it turned warmer: more cases were reported, but not in epidemic proportions, and confined to one part of town. But the reports were incomplete and it soon became evident that the plague had spread “beyond all hopes of abatement.”

When do you know that you face an epidemic: at the first death? when the trend is clear? And when do you know for sure what illness people are dying from?

London had a population of 500,000 in 1664. It was home to many illustrious scientists and physicians. But when the plague came what was known was not enough. “Where lay the seeds of the infection? How come it emerged when and where it did?” Why did the plague never again return in such a virulent form?

The plague came in bubonic, septicemic, and pneumonic variants. Symptoms were not always evident: many didn’t know they were infected for several days; they continued to move freely and spread the disease “till the inward gangrene affected their vitals and they died in a few moments” nor could the cause of death be known for certain until an autopsy was performed.

When should ‘The Authorities’ let the public know? To declare an emergency might cause panic and disruption; not to speak out might doom many who might heed the warnings and take precautions.

Fear and rumour compounded the risks. Quacks came from all parts to sell their nostrums at exorbitant prices. None of them worked; by the end the quacks had fled or were dead.

It seemed all regulations, precautions and remedies were useless. Abandoning hope, many went out and gathered freely, as if there was no infection. The plague spread faster.

The plague killed nearly everyone there was to kill in the infected parishes. At least 100,000 died. “Whole streets of families were swept away together.” It finally self-destructed like a fire that had consumed all its fuel.

WHAT YOU CAN DO WHEN YOU DON’T KNOW ENOUGH

Decentralize your “Assets”

“Let not such a contagion as this, which is chiefly dangerous to collected bodies of people, find a million of people in a body together. The plague, like a great fire, if a few houses only are contiguous where it happens, can only burn a few houses. But if it begins in a close-built town, and gets a head, there its fury increases: it rages over the whole place.”

Run for your Life

Get out of town early. The wealthy and those who could afford it left town. This exodus continued through May and June; spurred by rumors that the government was about to set up barricades on the roads. Without a Pass and a Certificate of Health “there was no way to being admitted to pass through the towns upon the road, or to lodge in any inn.”

Many of the poor, out of work and desperate, fled to the countryside. Many were not sick, but having no place to go, were forced to wander until they died of exposure and malnutrition, or from the disease.

“Country folk would carry out food and place it at a distance. When the wanderers died, the people would dig a hole to windward, and drag the bodies into these pits with long poles, and cover them.”

The Lord Mayor and other officials stayed at their posts. They used the City treasury to help sustain the poor. By order of the Lord Mayor, even at the height of the plague, bread and other basics were made readily available and price-gouging was forbidden. .

Avoid Contact

To quote an old maxim: “Shun it as if it were The Plague!”

Some families stockpiled food and other essentials and shut themselves in for the duration: keeping their houses “like little garrisons and suffering none to go in or come near them.” [Reminiscent of the early 1960’s nuclear attack panic -- bomb shelters in backyards, taking to the back woods, gun in hand to fend off neighbors.]

But in many households, someone had to venture forth to shop for food and other necessities, and inevitably came into proximity with others on the street and in shops, and brought the infection back into the home.

[Conventional disaster planning suggests keeping 72 hours of food and water on hand. In the event of a pandemic, 6 months of supplies would be a minimum!]

Destroy the (presumed) Carriers of the Infection

Not knowing by what agency the plague was communicated, they did what seemed reasonable: “We were ordered to kill all the dogs, cats, mice, and rats: for they are apt to run from house to house and might carry the infection in their fur.” [With Avian Flu, should we slay all the birds too?]

[The irony of killing off the cats and dogs was that they were the main anti-rat weapon, and it was the virus carried by the fleas on brown rats that carried the plague; but no one knew that at the time. Still, fleas do transfer to other carriers, and cats and dogs might have carried the disease that way.]

Get the Facts: Inspect and Verify

If anyone in a house had plague symptoms or fell dangerously ill without apparent cause of some other disease, the head of the household had to notify the authorities within two hours. But given what would happen to one’s household if one did report (see below), few would want to.

Examiners made sweeps of neighborhoods to list “what persons be sick and of what diseases, and upon doubt, to command restraint of access until it appear what the disease shall prove.” If you fell ill it was assumed you had the plague and you were quarantined at home until it proved otherwise.

Inspecting and verifying works when there are just a few cases. But when entire streets and neighbourhoods are stricken, few will dare go there.

Quarantine the Sick and Anyone or Anything in Contact with the Illness

The rules were first promulgated by James I during an outbreak in 1603: “Anyone found to be sick with the plague is to be shut up in the same house, and the house is to be quarantined for a month,” marked prominently and placed under watch day and night so no one leaves or enters.

Officials charged with visiting, examining, or nursing the sick, or with carrying away the dead, were ordered not to engage in any ‘social’ contacts. They had to carry signs warning others to keep clear [like a leper’s proverbial ten-foot pole with a bell on it.]

Sickroom beddings and apparel had to be fumigated or burned. Nothing could be removed from infected houses. The entire trade in second hand clothing and goods was shut down.

But when the plague spread the law became meaningless. Those under house arrest in close quarters with the plague knew they would die miserably if they stayed; so many tried desperately to escape. Those charged with standing guard had an incentive to accept hefty bribes to look the other way, or to desert (because duty and death marched together).

Plays, bear-baiting, games, singing, ballads, such-like causes of assemblies of people, and public feastings were banned. There was a curfew on taverns, ale-houses, and coffee-houses. Few ships ventured in and none were allowed to leave.

Have Enough Hospitals, Staff, Supplies, and Transportation ready Before “It” Happens

To be shut in at home with the plague meant death. Being treated at one of the two hospitals meant a chance of recovery. More hospitals and more physicians and nurses to staff them would have significantly reduced the mortality rate, would have provided a much more effective quarantine of the sick, and the general population would have been better protected [as was the case in Toronto during the SARS outbreak.]

The system could cope with small numbers of victims but could not handle the scale of the emergency: an epidemic can overwhelm resources and facilities -- more so if the infection runs its course through a victim in a matter of hours or just a few days..

At the start, there were many courageous doctors and nurses who valiantly did what they could, but they caught the infection and died: so by the time the epidemic reached its peak, the resources available to fight it had been reduced to a minimum.

Dispose of the Dead

The numbers to be buried at the peak (10,000 a week) almost overwhelmed the authorities. Only the most desperate and destitute, (and a few saintly souls), could be persuaded to take on the task of collecting and burying the dead (and the near-dead!). But “not withstanding the great numbers of dying and sick, the bodies were always cleared away and carried off every night, so it was never to be said of London that the living were not able to bury the dead.”

Prevent Crime

Greed, desperation, and an attitude that anything goes, led to break-ins of houses from which all the residents had been carried out dead. Some even stole the clothes and boots from the corpses of plague victims.

Do what is Necessary

Hippocrates said: “Desperate Circumstances may need Desperate [Creative] Responses.”
 

Chronicle of a Bio-Attack: London 1664-65 [from a 2001 column]

Introduction

Daniel Defoe was 5 during the 1664-65 London Plague. He wrote his ‘Journal’ (available as a Dover Thrift Edition reprint 2001) in 1722, drawing upon parish records, civic documents, and the memories of the living.

The Plague epidemic started slowly in September 1664, peaked terribly in the summer and fall of 1665 and then suddenly faded out. Official records suggest that one in four died. The true proportion was much greater: many people left town at the first hint of trouble.

Defoe describes a society caught up in a nightmare: not knowing what to do or where to turn. His “Journal” is presented haphazard. There are no chapter or section headings. It starts, moves on more or less chronologically, and ends. He repeats himself and is not always consistent. But he offers insights that could serve us well today.

I have reorganized and compressed his material: my apologies to his Shade, but I hope I have been true to his purpose.

London, 1665

London at the time of the Plague was by no means in the dark ages. It had a population of close to 500,000. It was an age of exploration and discovery. Science had become ‘popular.’ The Royal Society had recently been founded. Many scientists were also physicians: Gilbert (magnetism) and Harvey (anatomy) of particular note. Other illustrious names of the time: Newton, Hooke, Halley, and Boyle.

There were many more: it wasn’t unusual to find a group of them drinking together at say one of the better known coffee houses and talking about navigation, the structure of the universe, the state of naval architecture, and just about anything else. But when the plague came, what they knew was not enough.

Limited Early Warning

There were no newspapers, wire services, or TV journalists in 1664 “to spread rumors and reports of things, and to ‘improve’ on them.” The word came from abroad by letter from one merchant to another, and locally by word of mouth. This took time.

“But it seems the Government had a true account (of what was happening abroad) and several councils were held about ways to prevent its coming over; but all was kept very private.”

Description of Symptoms

There are three forms of Plague: bubonic, septicemic, and pneumonic. From Defoe’s descriptions, it appears the 1664-65 epidemic included bubonic and septicemic, and possibly pneumonic as well.

“The plague operated in a different manner on differing constitutions: some were immediately overwhelmed with it, and it came to violent fevers, vomitings, insufferable headaches, pains in the back, and on up to ravings and ragings with those pains, dying in dreadful manner.”

The Bubonic

“Others with swellings and tumors in the neck or groin or armpits … The swellings when they grew hard and would not break, grew so painful that it was equal to the most exquisite torture; and some, not able to bear the torment threw themselves out of windows or shot themselves. Others, vented their pain by such loud and lamentable cries to be heard as we walked along the streets that would pierce the very heart to think of, especially when it was to be considered that the same dreadful scourge might be expected every moment to seize upon ourselves.” “These were the worst visited, yet they frequently recovered, especially if the swellings could be brought to a head, and to break and run.”

Septicemic?

“Others, who did not develop these swellings died suddenly” “nor could physicians know certainly how it was with them till they (autopsied) them.” “Many that had the plague upon them knew nothing till the inward gangrene had affected their vitals, and they died in a few moments. This caused that many died in that manner in the streets suddenly, without warning.”

“Many persons never perceived they were infected until perhaps several days later, the ‘tokens’ came out on them: mortified or gangrened flesh in small knobs as broad as a little silver penny and hard as a piece of callus or horn. At that point they were beyond curing.”

THE FIRST CASES

Version One

“The first death occurred around Dec 20, 1664 in or about Long Acre; whence the first person that had the infection was generally said to (have caught it) from a parcel of silk imported from Holland, and first opened in that house. But after this, we heard no more of the plague until the 9th of February 1665 and then one more was buried out of the same house.”


Version Two

At the end of November 1664, two visitors from France died of the plague. The families tried to conceal the cause of death (fearing reactions of neighbors) but word spread. The authorities sent “two physicians and a surgeon” to inspect the house and they reported it was the plague. This was printed up in the weekly “Bill of Mortality” by the parish clerk, in the “usual manner: Plague: 2. Parishes infected: 1.”

In December, a third man died of plague in the same house. People all over town grew nervous. But there were no further deaths for six weeks, and everyone assumed it had been an isolated occurrence.

But on the 12th of February 1665, a fourth man died -- this time in another house but in the same parish. The weekly mortality reports began to show increases beyond the norm, and rumors spread that there had been many more cases of plague than the authorities were admitting. But the numbers, though on the increase, were still low, and confined to one part of town.

Lack of Trend, at first

“It is true it was a very cold winter and a long frost which continued three months, and perhaps the disease was’ frozen up.’ But the principal recess of this infection was from February to April -- after the frost had broken and the weather mild and warm.” “The numbers waxed, but then waned; and people were eager to assume all was well.”

The weather turned warmer, and there were reports of deaths from two other parishes -- yet the total deaths were but 54 for the whole city, and when in the next week the numbers dropped, there was a collective sigh of relief that the worst was over.

Then it became evident that the plague had in fact spread “beyond all hopes of abatement.” The official numbers were too obviously fabricated: the true death toll was many times higher than was reported, and everyone knew this.

“Perhaps it was that the disease was there, but in small numbers, and households could better conceal the truth about cause of death from the official rolls -- until the numbers grew so high that no concealment was possible.”

It was a hot summer, and “the infection spread in a dreadful manner…the bills rose high; the articles of the fever, spotted fever, and teeth began to swell.”

By mid-July, the plague was progressing through the town. It kept mainly to the more crowded, poorer, sections, but perceptibly, was moving on the more affluent.

“The question is this: Where lay the seeds of the infection all this while? How came it to stop so long, and not stop any longer?”

DEFENSIVE MEASURES

Concealment

All that could conceal their illness did so: “to prevent their neighbors cutting them off, and also to prevent the authorities from sealing their homes: this was not yet practiced, but was threatened, and people were terrified at the thought of being sealed in and isolated to die.”

Flight

The wealthier people removed themselves from town in large numbers. “For some weeks that there was no getting at the Lord Mayor’s door without exceeding difficulty: to get passes and certificates of health, for without these there was no way to being admitted to pass through the towns upon the road, or to lodge in any inn.”

This exodus continued through May and June, spurred by rumor that the Government was about to establish barricades on the roads to prevent people from London passing -- for fear they would bring the infection with them. It was not a good time to fall ill; if you complained, it was assumed you had the plague.

“It was thought that there were not less than 10,000 houses abandoned by their occupants, besides the numbers of lodgers and particular members who were fled out of other families, so that in all it was computed that about 200,000 people were fled and gone.”

Some (who left later on) “perished in the street or fields for mere want, or dropped down by the raging violence of the fever upon them. Others wandered into the country, and went forward any way, as their desperation guided them, till not getting any relief, the houses and villages on the road refusing to admit them whether infected or no, they perished by the roadside or in barns -- none daring to come to them or to relieve them, though perhaps not infected, for no one would believe them.”

Many of the poor -- being destroyed not only by the infection but as much by the consequences of it (lack of employment) -- in desperation, fled the city, but only found death on the road; “and they served for no better than the messengers of death, for some carried the infection with them into the country.”

The country folk did what they could: carrying out food and placing it at a distance. When the wanderers died, the country folk would dig a hole at a distance from them to windward, and then, with long poles and hooks, drag the bodies into these pits and cover them. Those that so died, and others unknown, are not included in the statistics.

“The face of London was now strangely altered. Sorrow and sadness sat upon every face. Everyone looked on himself and his family as in the utmost danger. The shrieks of women and children at the windows and doors of their houses, where their dearest relations were perhaps dying, or just dead, were so frequent to be heard as we passed the streets.”

Portents and Superstitions

A comet appeared several months before the plague came, and another just before ‘The Fire’ (1666). In hindsight, “these things had a more than ordinary influence upon the minds of the common people.” Prophecies, astrological conjurations, dreams, and old wives’ tales took hold. Would-be preachers ran through the streets with apocalyptic shouts and further alarmed the populace.” There were instances of crowds caught up in “mysterious visions.”

“This folly presently made the town swarm with a wicked generation of pretenders. Purveyors of nostrums had a field day: ‘Infallible preventive pills against the plague’; ‘Sovereign cordials against the corruption of the air’ ‘Anti-pestilential pills’.” [We in our day are also bombarded with such claims].

Supposedly eminent healers from abroad [the gurus and miracle workers always hail from far away] set up shop and touted their prowess: “newly come over from where he resided during all the time of the great plague last year, and cured multitudes of people.”

“But there was still another madness beyond all this, which may serve to give an idea of the distracted humor of the poor people at that time: in wearing charms, philters, exorcisms, amulets, and I know not what preparations, to fortify against the plague…that it was to be kept off with crossings, signs of the zodiac, papers tied up with so many knots, and certain words or figures written on them, as particularly the word Abracadabra, formed in triangle or pyramid.”

But these charms did not help, and all too many poor souls were “carried away in the dead carts and thrown into the common graves of every parish with these hellish charms and trumpery hanging about their necks.”

By the end, all the predictors, astrologers, fortune-tellers, and what they called cunning-men, conjurers and the like “were gone and vanished: not one of them was to be found. Many went to their long home, not able to foretell their own fate.”

Who to Turn To in Extremity?

As the plague spread, the populace gave up their trust in the quacks, but then, not knowing what to do, or who to turn to, they ran frantically around: calling on God, and asking one another “What shall we do?”

Many “turned to prayers, fasting, and ‘humiliation’, and imploring the mercy of God. But “neither can I acquit those ministers that in their sermons rather sank than lifted up the hearts of their hearers.”

With imminent death looming, many, especially the dying, repented of past actions. “But none durst come near to comfort them.” “Some of the ministers did visit the sick at first, but it would have been present death to have gone into some houses. The very buriers of the dead, who were the hardenest creatures in town, were sometimes so terrified that they durst not go into houses where the whole families were swept away together -- but time inured them to it all.”

Actions by the Authorities

“At the start, the Lord Mayor and the sheriffs, the Court of Aldermen, and a certain number of the Common Council men, or their deputies, came to a certain resolution, and published it: that they would not quit the city themselves, but that they would be always at hand for the preserving good order in every place, as also for the distributing the public charity: for doing the duty and discharging the trust reposed in them by the citizens to the utmost of their power. And they were in fact continually in the streets and at places of the greatest danger. [We have witnessed similar courage and leadership, by many in our own time; and ‘sauve qui peut’ cowardice from a few].

The finances of the City were in good shape, and used generously to sustain the poor. (many were unemployed now because Trade was ‘stopped’, and also, the city was largely depopulated or closed up). Few ships ventured up the river, and none were allowed to leave. Every family retrenched their living as much as possible. The Royal Court contributed considerably (but kept their physical distance). Many of the wealthy who had left town gave generously for relief of the poor.

Bread and Provisioning

Thanks to the authorities, even at the height of the epidemic, provisions were always to be had in full plenty, and the prices not raised much.

“Neither was there any want of bakers or ovens kept open to supply the people. The Master of the Bakers’ Company, was, with his court of assistants, directed to see the orders of my Lord Mayor for their regulation put in execution: the due assize of weekly bread observed; all the bakers obliged to keep their oven going constantly.”

Pest-Houses

There were only two ‘pest-houses’ to house the sick. “If there had been, and if a person, as soon as he fell sick, could have been removed there, the number of fatalities would have been greatly reduced.” “Very good physicians were appointed, so that many people did in fact come out of them well again: in all the time of the visitation, there were but 300 buried from the two houses, in total.”

The lack of hospitals meant shutting up the well with the sick at home. This was a powerful inducement for the others to escape -- to further transmit the sickness.

Quarantines

There was a necessity in this extremity to look to law and order, and it was done.

Starting in June, the authorities established emergency regulations. Houses in some parishes were “shut up” -- guarding against entry or exit. The dead were taken and buried immediately. The plague ceased in those streets: early vigilance is an essential weapon in the struggle.

This shutting up of people in their own houses was first used in the London plague of 1603 under “An Act for the charitable Relief and Ordering of Persons infected with the Plague.” Anyone found to be sick with the plague was to be immediately sequestered in the same house, and even if he recovered, “the house shall remain shut up for a month.”

*To quarantine the infection, “the sickroom beddings and apparel, etc. must be well aired with fire and “such perfumes as are requisite within the infected house.”

*Any person who visits a person known to be infected or who entered willingly into a known infected house, “his house too is to be shut up.”

*No one can be removed from the house where he fell sick except to the “pest-house or a tent” or to a house where the owner/occupier accepts full responsibility. If a person owns two houses, he may send either his sound or his infected people to the second house: the second house also being shut up then for a week, in case of undetected cases.

*Every house visited by the plague is to be marked with a large red cross.

*Searchers, Chirurgeons, Keepers, and Buriers are to hold a red rod of three feet in length, open and evident; they are to abstain from company, and must not enter any home except their own or to where they are officially sent.

*Hackney-Coachmen [Taxis] must air their coach and place it in quarantine for 5 days after carrying an infected person.

The shutting up of houses was at first looked on as very cruel and ‘unchristian.’ “But it was a public good that justified the private mischief.” “But it was not to be depended on. It served to make those confined desperate, and they resorted to extremities, including assault upon the watch, and even murder to break out.”

From those shut up “we heard the most dismal shrieks and outcries of the poor people, terrified by the sight of the condition of their dearest, and by the terror of being imprisoned as they were.” For, if one member of a household fell ill with the plague, and the rest of the household were ‘shut up’ with the sick person, it was almost certain that all would die. Some are on record as actually dying of fright; many were traumatized to the point of going mad; and some lost their memory of those events.

Self-Quarantine

On the other hand, many families, warned that the plague was coming, put up provisions and shut themselves in; not being seen or heard of until the epidemic was over: “keeping their houses like little garrisons: suffering none to go in or come near them.”

In the beginning of August, the plague grew ‘very violent’, and ‘my doctor friend’ coming to visit me, and finding that I ventured so often out into the streets, earnestly persuaded me to lock myself up and my family; to keep all our windows fast; shutters and curtains close; and never to open them.”

“People walked in the middle of the street, so they would not mingle with anyone that came out of houses, or meet with smells and scent from houses that might be infected.”

Inspections

The master of any house, as soon as anyone in his household complained of “blotch or purple or swelling in any part of the body or who fell dangerously sick “without apparent cause of some other disease,” had to notify the Examiner of Health within two hours.

Examiners made sweeps of neighborhoods to list “what persons be sick, and of what diseases, and upon doubt, to command restraint of access until it appear what the disease shall prove.” Every infected house was to be under watch day and night.

Women Searchers, “of the highest and most honest repute”, were appointed to inspect the dead to make sure of cause of death. “No Searcher during this time of visitation was permitted to use any public work or employment, or keep any shop or stall, or be employed in any common employment whatsoever.”

Any “Nurse-Keeper” who removed herself out of an infected house before 28 days after the decease of any person dying of the infection, both she and the house to which she removed herself was also quarantined for a further 28 days.

Disposal of the Dead

Thanks to the authorities, even at the height of the epidemic, no dead bodies lay unburied or uncovered: *The dead are to be buried before sunrise or after sunset. No neighbors or friends are allowed to attend. *No corpse dead of infection is to be buried or remain in any church at a time of common prayer etc. (where others are present for services). *Children are not allowed to come near the corpse, coffin, or grave.

*All graves are to be at least six feet deep. “They dug several great and deep pits into which they put 50 bodies each; then they made larger holes wherein they buried all that the dead-carts (in that parish) brought in a week.” At the beginning of September the numbers of bodies to be disposed of was increasing: “people that were infected and near their end, and delirious also, would run to those pits, wrapt in blankets or rugs, and throw themselves in, and expired there.” (At the height of the epidemic, the numbers to be buried across the city ran to 10,000 a week, concentrated in a few parishes!)

There were problems excavating large and deeper pits: the water table was encountered at twenty feet depth.

Sanitation

[These regulations are all sensible; more so in a time when they had no clear idea of what the Plague was, or how it was spread].

*No clothes, stuff, bedding, or garments can be removed from infected houses. (Dealers and trade in second hand clothing and goods were ordered closed down). Some turned to fumigation and fire to purge infected houses and goods: burning brimstone, sulfur, pitch, and even gunpowder!

In 1666, the Great Fire did indeed destroy remaining traces of infection in much of the City. But not in all. Defoe asks: “How has it been that the plague has not come back in all those great parishes where the fire never came, and where the plague raged with the greatest violence?”

*The streets are to be swept clean: every householder must do so daily before his door. *The sweepings and filth of houses is to be carried away daily.

*No poor quality produce or fish or meats is to be sold. Breweries and drinking establishments are to be inspected for “musty and unwholesome casks.”

*No hogs, dogs, cats, tame pigeons, or conies, are to be kept in any part of the city (see below under “How the Plague was Spread”).

Restraints on Public Gatherings and Converse

*No wandering beggars. *“No plays, bear-baitings, games, singing of ballads, or such-like causes of assemblies of people. No public feasting till further order. *A Curfew on taverns, ale-houses, and coffee-houses.

THE EPIDEMIC RAGES

The Medical Profession

Physicians were appointed “for relief of the poor.” The College of Physicians was asked to publish recipes for cheap and effective remedies: this helped at least to turn the populace away from the quacks, their nostrums, and the use of outright poisons.

But “the violence of the distemper, when it came to its extremity, was like the fire the next year. The fire, which consumed what the plague could not touch, defied all the application of remedies; the fire-engines were broken, the buckets thrown away, and the power of man was baffled and brought to an end. So the plague defied all medicines, the very physicians were seized with it, with their preservatives in their mouths, and men went about prescribing to others and telling them what to do till the tokens were upon them, and they dropped down dead. Many of the most eminent died of the infection.
Abundance of quacks too died, who had the folly to trust to their own medicines.”

“Not that it is any derogation from the labor or application of the physicians to say they fell in the common calamity; it is rather to their praise that they ventured their lives so far in the service of others. Doubtless they helped many by their skill, and their prudence. But they could not cure those that had the tokens upon them, or who were mortally infected before the physicians were sent for.”

How the Plague was Spread

There were many theories about how the plague was spread. The more enlightened assumed an ‘infection’ transmitted by some unknown agency -- possibly airborne. Others considered it a punishment from Heaven and therefore without agency.

“The plague is carried from house to house in the clothes.” It first broke out in a house where goods from the Levant by way of Holland had been carried. It spread from there carried by those made sick to those with whom they had conversation.

“The best physic against the plague is to run away from it.” “Consider separating the people into smaller bodies, and removing them (before the plague comes) farther from one another, and let not such a contagion as this, which is indeed chiefly dangerous to collected bodies of people, find a million of people in a body together. The plague, like a great fire, if a few houses only are contiguous where it happens, can only burn a few houses. But if it begins in a close-built town or city, and gets a head, there its fury increases; it rages over the whole place, and consumes all it can reach.”

Infection generally came into a house because members of the household went out to shop -- for food and other necessaries, and in so doing, came into proximity with others on the street and in shops, etc.

“Nothing was more fatal to the inhabitants of the city than the supine negligence of the people themselves, who, during the long notice of warning, made no provision for it by laying in store of provisions, or of other necessaries, by means of which they might have lived retired and within their own houses: those who did were in great measure preserved by that caution.”

“However, the poor could not lay up provisions, and must go to market to buy; this brought abundance of ‘unsound’ people to the markets, and a great many went thither sound brought death home with them.”

At the height of the plague, The Lord Mayor caused country people who brought provisions to sell in the city to be stopped at the outskirts (in informal markets) where they sold what they brought and then went away. This precaution encouraged country folk to bring the food to the city that the people needed.

“We were ordered to kill all the dogs and cats; for they are apt to run from house to house and from street to street, and are capable of carrying the infection in their fur. All possible endeavors were used also to destroy the mice and rats -- especially the latter, by laying poisons for them, and a prodigious multitude of them were destroyed.”

Crime

There were many robberies and “wicked practices”. “The power of avarice was so strong in some that they would run any hazard to steal and to plunder, and particularly in houses where all the inhabitants have been dead and carried out, and without regard to infection take even the clothes off the dead bodies and the bed-clothes.”


At the Height of the Plague

From the middle of August to the middle of October, the official records show thirty to forty thousand died of plague. Another ten thousand were recorded as dying of other causes -- but most of those were probably due to one or other form of plague, or its consequences.

But it was impossible to know the real totals: clerks, administrators, and those on the ‘front line’ were overwrought simply trying to gather and bury the dead. The true toll probably reached two thousand a day at the height. There were likely at least 100,000 victims of the plague in 1665 alone. “There was not a town within ten or twenty miles of the City but that was more or less infected.”

“Whole families and indeed whole streets of families, were swept away together. It was frequent for neighbors to call to the bellman to go to such-and-such houses, and fetch out the people, for that they were all dead. By then, the work of removing the dead bodies had grown extremely dangerous; innumerable of the bearers died of the infection. Yet there was such need of employment that others of the poor were always ready to take on the work. So, not withstanding the great numbers dying and sick, the bodies were always cleared away and carried off every night, so it was never to be said of London that the living were not able to bury the dead.”

With those died, and those who had left town, there were not one-third as many people in town during August and September as there had been in January and February.

“After funerals became so many that people could not toll the bell, mourn or weep, or wear black for one another; nor so much as make coffins for those who died; so after the fury of the infection appeared to be so increased, in short, they shut up no houses at all. It seemed enough that all the remedies had been used until they were found fruitless.”

“People began to give themselves up to their fears and to think that all regulations and methods were in vain. I do not mean a religious despair, or a despair of their eternal state, but I mean a despair of their being able to escape the infection or to outlive the plague, which they saw was so raging and so irresistible in its force.”

“People in this despair turned bold and venturous: they were no more shy of each other, or restrained indoors, but went anywhere and everywhere, and began to converse: ‘tis no matter who is all sick or who is sound.’ As it brought people into public company, so it brought them in large numbers into the churches. ‘A near view of death soon reconciles men of good will to one another, and bring us to see with differing eyes than those with which we looked on things with before.’ But as the terror abated, those things all returned again to their less desirable state.”


THE END OF THE EPIDEMIC

“It was even at the height of this general despair that the plague began to slacken, surprisingly, even as it had come.”

In September, the plague abated in the west and north-west parishes (so dreadfully visited at the first), but raged elsewhere in the city through the beginning of October. Then, as October wore on, the plague diminished both in numbers infected and in its intensity so that the proportion of deaths among those infected dropped. People grew careless, and for a time the numbers increased again. But the contagion was ‘exhausted,’ and winter weather came: the air was cold and clear, with sharp frosts. Most of those fallen sick recovered.

Not withstanding the violence of the plague in London, it was never on board the fleet.

Editor's notes: I thought it would be useful to group all of David Newman's Big Med musings on pandemics on one 'page.' He will be sending along other thoughts on this topic.

If you've got questions/suggestions for David Newman, please send them to ideas@tems.ca

Pandemic Revisited [Sep 6 07]

Danger Pay [Aug 27 07]

Ethics and Triage: A Nasty Scenario [Dec 12 06]

Pandemic Flu Planning: "A Flow is a Quantification of Assumptions" [Dec 6 06]

The London Plague of 1664-65: Summary [from 2006]

Chronicle of a Bio-Attack: London 1664-65 [from 2001]

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