Plague Hospitals from Medieval times to Spanish Flu: Precedents for an ‘unprecedented’ pandemic. An essay by Sophie Byatt
The word ‘unprecedented’ has been used ad nauseum to describe the current virus and its impact. So much so, that those in the media are complaining about the unprecedented use of the word itself. The truth is that plagues and pestilence of all kinds are very much precedented and are as old as time, or possibly even older.
This article takes a look at the role of hospitals, such as the one built in the 13th century on the land in Arbroath that became known as Hospitalfield. Somewhat different from the role of contemporary hospitals, these institutions cared for the spiritual and corporeal health of communities. I go on to consider some of the most striking parallels between events and our response to them in the current crisis and how we have reacted to similar challenges to those that took place during plagues past.
In some respects we can set straight the myth that today’s events are “unprecedented” and in others, examine how things have changed through the centuries. For example, quarantine or “self-isolation” as we now refer to it, is thought to have been first introduced in 1347 during the Black Death; an early example of “lockdown” took place in the village of Eyam in Derbyshire with the arrival of the plague in 1665, so 2 major pillars of our strategy to control the spread of Covid 19 certainly have precedents going back centuries.
Plagues in the medieval world – 5th to the 15th century
It is safe to suggest that an extensive range of illnesses and epidemics have been with us for as long as humans existed, although we know to our cost that new ones are constantly evolving. Nowadays, developments in DNA testing of skeletal remains means that archaeologists can often identify cause of death for those living many thousands of years BCE, for example identifying diseases such as tuberculosis, leprosy or even cancer. So, if plagues have been with us since the dawn of time, how have those in authority tried to limit the spread of disease and how have we tried to care for the sick in these times of great sorrow?
The medieval world (5th to the 15th century) was beset with plagues; outbreaks of the sweating sickness, leprosy, dysentery and bubonic plague (the Black Death) all killed swathes of the global population. Could the sick turn to anyone for help? With little knowledge of medicine in a world where illness was thought to be caused by the movements of the planets, care was sparse. An apothecary might concoct potions, perhaps made from honey, dried toad or horse saliva, but these treatments were both expensive and ineffective.
The medieval period saw the foundation of hospitals, by kings and religious orders across Europe. These hospitals were unlike those we know today, their primary purpose was to operate as communities dedicated to prayer and worship. As part of their religious duty, they offered shelter for pilgrims and care for the sick and infirm, particularly for those suffering from leprosy. They were often also centres for learning. The word hospital comes from the Latin hospitalis which refers to hospites meaning guests and guests were those who required shelter.
The Hospitaller Order of St John of Jerusalem (the Knights of Malta) founded hospitals specifically to care for pilgrims to the holy land and the Benedictines founded a network of hospitals across Europe dedicated to caring for the sick. The hospital built in the 13th century on the site where now the 19th century Hospitalfield House stands, was a fine example, founded by Tironesian monks to support the vast Arbroath Abbey. This hospital, built in the fresh air just outside the town overlooking the sea, was originally a leprosy and plague hospice called the Hospital of St John the Baptist. The hospital movement was a significant step in providing care for the sick and needy; in a world where life expectancy was low the existence of heaven and hell was regarded as an inviolable reality, monks combined the business of nurturing both spiritual and physical well-being.
The hospital movement spread through Europe with a 225-bed hospital being built at York in 1287 and even larger facilities established at Florence, Paris, Milan, Siena, and other medieval big European cities at roughly the same time.
The main purpose of medieval hospitals was three-fold: prayer and spiritual contemplation, education and learning and caring for the infirm, the elderly, pilgrims and those with leprosy. For much of the time, hospital life may have been relatively attractive and even prosperous. Leprosy was not particularly contagious, there was no cure, but death rates were low, estimated at 2 in 10 cases. Hospitals received bequests and donations, benefactors would support hospitals in the hope that this would gain celestial approval when a smooth passage heavenwards was required, and, in some cases hospitals could even collect taxes. However, during plague outbreaks, hospitals were quickly overwhelmed. Without any effective treatment and with death rates for the plague at around 100% many hospitals, monks and patients alike, were simply wiped out.
14th Century: The Black Death 1334 to 1353
The Black Death can be considered as topping the league of great pandemics. It swept through Asia and Europe, believed to have started around 1334 it spread along trade routes with merchants and traders travelling by horse, camel and ship.
Whilst there was no treatment for the plague or indeed much understanding of how it spread, it was known to be contagious. In 1337, one of the first recorded “precedents” for quarantines was introduced in modern-day Dubrovnik (then known as Ragusa), the edict read “those who come from plague-infested areas shall not enter [Ragusa] or its district unless they spend a month on the islet of Mrkan or in the town of Cavtat, for the purpose of disinfection.” Social distancing had become official.
Around 1348 the Black Death arrived in the UK, quickly travelling to Scotland. John of Fordun (d.1384), provides a contemporary report in Scotichronicon, echoing our current crisis:
In 1350, there was a great pestilence and mortality of men in the kingdom of Scotland, and this pestilence also raged for many years before and after in various parts of the world. So great a plague has never been heard of from the beginning of the world to the present day, or been recorded in books. For this plague vented its spite so thoroughly that fully a third of the human race was killed. At God’s command, moreover, the damage was done by an extraordinary and novel form of death. Those who fell sick of a kind of gross swelling of the flesh lasted for barely two days. This sickness befell people everywhere, but especially the middling and lower classes, rarely the great. It generated such horror that children did not dare to visit their dying parents, nor parents their children, but fled for fear of contagion as if from leprosy or a serpent.
Anti-semitism in Europe greatly increased as a result of the Black Death at this time, as communities blamed Jews for the spread of the disease and as a result, some Jewish communities were completely wiped out. Similarly blaming Spain for the Spanish Flu outbreak in 1918 is now known to be unjustified as the epidemic certainly didn’t start there, and naming it as such is known to have caused great offence at the time. In 2020 the fact that Covid 19 originated in China has resulted in an increase in hate crime against those of east Asian heritage. So again, little is unprecedented down the ages when it comes to apportioning blame.
In 1300 the population of Britain has been estimated at 3 million and during the early years of the century, the population grew still further due to unusually good harvests. It is widely believed that the Black Death killed between 30 to 45% of the population, almost half the population and in some cases the populations of entire towns and villages perished. The massive death rate presented the hideous issue of how to dispose of the dead. Churchyards were quickly overwhelmed and plague pits became the pragmatic solution in a grisly crisis. This 14th century challenge is matched today with morgues and crematoria reporting a huge increase in demand for their services, resulting in delays of many weeks for funerals, although less shocking solutions have been found with the creation of temporary morgues across the UK.
The sudden reduction in population and the suffering of communities had a devastating impact on the economy, as one contemporary chronicler,Geoffrey the Baker wrote of Bristol in Chronicon Angliae:
…At this period the grass grew several inches high in the High Street and in Broad Street; it raged at first chiefly in the centre of the city.
Immediately following the Black Death trade slumped and war briefly ceased. It is thought, however, that both picked up fairly swiftly, a longer lasting impact was the shortage of labourers to work on the land due to the death of so many or the working poor. An unintended consequence was that wages or payments for labour, actually rose in the period following the Black Death. Such was the demand for labour that if one landowner didn’t pay their tenants well, tenants could simply move on to the next landowner and be assured of work and remuneration. Prior to the Black Death the landowners and lords of the manor controlled wages, peasants were tied to the land with few choices and no bargaining power in terms of rates of pay. The dramatic reduction in people to work the land meant that peasants could demand greater pay or move on, this new mobility had not been possible previously. There was no equivalent of a furlough scheme but a period of relative freedom, if not exactly prosperity, followed for those who had never known it before. The income of lords fell by 20% from 1347 to 1353 whilst a ploughman making 2 shillings a week before the plague demanded 3 shillings weekly in 1349 and 10 shillings weekly in 1350. Unfortunately this scenario is unlikely to be repeated post Covid 19.
In the 15th century Venice was the foremost global trading and financial centre in the world. The City held a virtual monopoly on the spice trade and its geographical position at the centre of trading routes, including the Silk Route made Venice the port that linked the world from East to West. This global trade sadly also put the City at the epicentre of the spread of disease. The Venetians knew that their prosperity depended on trade so organised to limit the impact. In 1423 the Venetians founded the first permanent plague hospital, Lazaretto Vecchio. Situated on a lagoon island away from the city, this distance enabled sick people to be isolated from the main populace and also to be treated and cared for. The Lazaretto combined the provision of quarantine with medical care and was well-funded by the government of Venice. The modern day World Health Organisation (WHO) would have approved of this development in their strategy to stem the spread of infection and the opening of this permanent hospital specifically for the treatment of the plague also chimes with our current experience; namely that plagues devastate economies and economies can only be revived if and when the infection is under control.
The Great Plague of 1665
The plague continued to erupt across Europe continuously throughout the 16th and 17th centuries, including a “spike” known as the Great Plague of 1665-6 which centred in the UK on London where it is thought to have killed 25% of the capital’s population, perhaps around 100,000 people.
Measures that sound familiar today were put into force. Ships coming into the Port of London were quarantined, travel within the country was restricted, houses known to include residents with the disease were shut up and guarded, and in some cases, sick people were sent to pest houses in an early attempt at isolation, if not quite self-isolation. Pest Houses were introduced in the 14th century and their name comes from the French word for the plague, la peste. Whether there was any treatment or care at pest houses is up for discussion, but considering the panic, widespread death and devastation wreaked by the plague it is perhaps unlikely.
Businesses were closed and those who could afford it fled the city, leaving the rest to their fate. Around 100,000 people are thought to have died during this time. As mentioned earlier, the village of Eyam in the Peak District, pioneered an early example of a local lockdown. When the village’s vicar realised that the local tailor had died from plague, terrified of spreading the infection, he led the village into strict lockdown; boundary stones were set at the edges of the village which still stand today, and no-one was permitted to enter or leave. This selfless strategy prevented the infection from spreading, however 267 of the 344 inhabitants died from the disease.
The plague of 1665-6 didn’t spread to Scotland, presumably because the council of Scotland closed the border with England in what seems to have been a very effective and speedy lockdown order.
Once again, the economic impact was devastating but thought to be short-lived. It has been suggested that the great fire of London the following year provided an economic stimulus as London had to be rebuilt. However at the time, there was great suffering, not only as a result of the plague but also because poverty and starvation led to increased beggary and thieving. Pepys writes in his contemporaneous diary, “the plague is making us as cruel as dogs to one another”.
Then as now, the number dying from the disease was a matter of public record, currently we have the Office for National Statistics providing reliable data, in the 17th century each London parish recorded the number of dead together with cause of death, these numbers were added together and published in Mortality Bills.
As the Renaissance led into the age of enlightenment, epidemics continued to occur across Europe. Cholera, diphtheria, yellow fever, typhoid, to name but a few, all created devastation in a time before treatments such as antibiotics and vaccines. However the renaissance brought with it an intense focus of scholarship and discovery and this set the foundation for historic discoveries in medicine and medical care.
The new age also saw the founding of the voluntary hospital movement which was established in the early 18th century. Rapid escalation in populations across Europe, high infant mortality rates and the recognition of the impact of unsanitary conditions in cities all led to official acknowledgement of health issues and at least some attempts to meet health challenges. New hospital openings included the Westminster Hospital in 1720, the Royal Edinburgh Infirmary in 1729 and Manchester Royal Infirmary in 1752 amongst others.
From the 18th to the 20th century significant steps on the ladder of public health were taken by scientists and doctors to limit the spread of infection and treat disease. As scientists began to learn more about contagion, isolation or fever hospitals were introduced. In 1741 The London Smallpox Hospital opened, followed by the Liverpool Fever Hospital in 1801 and the Glasgow Parliamentary Road Fever Hospital in 1865.
Fever hospitals were a hugely significant development in the treatment of communicable diseases, so much so that now, in 2020, there has been a call for their return. They are the very epitome of an isolation strategy. A quote from the Spectator article of 15th May 2020 reads:
“They contained isolation wards, separate accommodation for different infections, laboratories, operating theatres and convalescent wards with activities for recovering patients. Given the current problems of the Covid-19 outbreak, we need to re-establish these medical relics.”
As an early strategy for the containment of contagious diseases fever hospitals have much to recommend them. Those with contagious diseases were sent to their local fever hospital, often situated on the outskirts of towns, and cared for locally and in isolation.
The introduction of fever hospitals led to complaints from those living nearby who lived in fear of infection, it was in fact found that the incidence of smallpox increased near smallpox hospitals. This resulted in the siting of hospitals next to rivers so that patients could be transported by ambulance steamers. Ships in London were also used as isolation hospitals.
Life expectancy between 1500 and 1800 is reported as having been between 30 to 40 years of age and from the 1800s, life expectancy started its gradual rise, due to the improvements in public health that started in the early 18th century.
In 1848 The General Board of Health was established to advise the government on public health matters, specifically including quarantine and isolation as a means of stopping the spread of infectious diseases. In 1899 the Infectious Diseases Notification Act meant that local physicians were obliged to report cases to the local sanitary authority so that isolation procedures could be immediately implemented.
A structure started gradually to be put into place to manage health emergencies, in 1848, after a major cholera outbreak which killed 50,000, the Public Health Act resulted in the establishment of the General Board of Health which was specifically tasked to advise on issues such as the management of epidemics and general disease prevention. Although this was not an early Scientific Advisory Group for Emergencies (SAGE) the origins of government and legislative involvement in health can be clearly seen.
The establishment of the board was as much about protecting the economy as it was about caring for sick people. A leading member of the group who established the General Board of Health was a social reformer called Edwin Chadwick, his view was that “if the health of the poor were improved, it would result in less people seeking poor relief. Money spent on improving public health was therefore cost effective, as it would save money in the long term.” Therefore, the implementation of health reform could be described as a way of preventing more people from accessing the 19th century equivalent of social security payments. Then, as now unsurprisingly, the impact of plagues extensively increased the numbers of those claiming any benefits available to them. Local Health Boards were set up in 1858 to improve sanitary conditions and in 1854, led by Florence Nightingale, improvements in hospital hygiene were introduced.
The next “unprecedented” global health challenge was around the corner, the great influenza epidemic of 1918-20. Known as the Spanish flu, it is not known where it originated but the first documented case was on a military base in Kansas USA.
Is the word “unprecedented” used correctly in this case? Whilst the plagues of 1334 and 1665 spread via early trade routes, travelling by horse, camel or under sail, the Spanish flu was transferred by troop ship, train and the efficient transport of the First World War. It was incubated in the crowded conditions of war and was exacerbated by the fact that individuals and social structures were already weakened by the impact of 4 years of conflict. It was also the first time that soldiers from across the whole world were on the move to gather for battle and then, in 1918, when hostilities ended, they travelled the globe to return to their homes en masse, taking the virus back with them to their families.
Medical advances meant that there was a healthcare structure in place and a significant increase in knowledge of palliative care and the importance of good hygiene, there was, however, no cure. Had the pandemic occurred at any time other than at the end of a devastating war when services were already weakened, hospitals may have been better able to cope.
It is estimated that the Spanish flu killed between 17 and 100 million people across the world. As news of the deadly disease spread, countries that were at war censored information in the media in order to suppress local fear and panic. However, Spain was neutral and so was able to report fully on this new and deadly disease. The pandemic gained the name Spanish flu for this reason. Certainly, the censorship of news of the pandemic delayed precautions being put into place in the UK, thereby increasing the death toll.
Glasgow was the first place in the UK to record an incidence of the flu in May 1918 and by the end of the summer of 1919 a quarter of the British population had been affected and 228,000 people in Britain had died. Little effective treatment was available and although herd immunity was not an option that was selected, it was the de facto outcome for this particular pandemic.
As the pandemic spread across the UK, a Scottish physician, Dr James Niven, Public Health Officer for Manchester is credited with being the first person to introduce preventative measures to slow the spread of the disease. He recommended the closure of schools and cinemas and he had public service information leaflets printed and distributed widely informing Manchester residents of the precautions that they should take to avoid infection. His leaflet urged that crowds should be avoided, that the sick should not go to work and that sufferers should have their own rooms which were to be well ventilated. The wearing of masks was recommended and became commonplace.
Dr Niven’s eventually followed in Manchester and, as a result, Manchester experienced a significantly lower mortality rate than the rest of the UK. However they were initially rejected by Sir Arthur Newsholme, Chief Medical Officer of the Local Government Board who wrote “I know of no public health measure which can resist the progress of pandemic influenza”.
Local authorities and the press offered advice for social distancing such as such as catching later trains to avoid crowds, giving up shaking hands and giving up kissing.
As the numbers of those infected grew both in the population and amongst medical professionals, student doctors were drafted in to help and hospitals were entirely given over to caring for flu patients. The sheer number of sick meant that many of Spanish flu patients were cared for at home, with doctors making occasional visits. In another horrific echo of plagues gone by, a shortage of undertakers and grave diggers meant that bodies lay unburied for days at a time, many funerals took place at night.
Dr Basil Hood of Marylebone hospital was one hero of the pandemic who wrote extensively at this period. Then as now, the sheer dedication of the medical profession shines through and is both inspiring and humbling. In his writing, the horror of the disease is as stark and the indomitable spirit of the medical profession who battle it is as moving in 1918 as it is in 2020:
“The staff fought like Trojans to feed the patients, scramble as best they could through the most elementary nursing and keep the delirious in bed! Sad to relate some of these gallant girls [nurses] lost their lives in this never-to-be-forgotten scourge and as I write I can see some of them now literally fighting to save their friends then going down and dying themselves.” – Dr Basil Hood
It is difficult to extract the economic impact of the Spanish Flu epidemic of 1918 from the similarly devastating impact of the First World War. Then as now, major cities closed businesses and banned gatherings of all types. As a result of the enormous death toll, there were labour shortages similar to those seen in the Black Death of 1334 and in 1918, as in 1334, this also led to wage increases. Edwin Chadwick’s observation that mortal diseases cause a significant increase in the numbers claiming social security benefits was also shown to be true in 1918, as it has been in 2020. However, it has not been possible to find a figure covering loss of GDP as a result of the Spanish flu as this cannot be identified distinctly from the consequences of World War I.
The 1918 pandemic burned itself out eventually in 1920, but has been followed by many other plagues subsequently, Avian Flu, Swine Flu, SARs and Ebola to name but a few which have occurred in recent years.
It can only be hoped that we will learn so much from our experience of the Covid 19 pandemic of 2020, that future outbreaks, when they come, will result in lower death tolls, reduced suffering and greater consistent consideration for those key workers who will sustain society during plague years to come.
With grateful thanks to all those who work in the medical and caring professions at all times, but especially during the time of plagues and pandemics.