A Conversation with Medical Historian Frank M. Snowden from Rome on COVID-19, the Situation in Italy, and the History of Epidemics

My home state, Washington, became ground zero for the coronavirus or COVID-19. On February 28, 2020, the mysterious disease took the first life in the US at a long-term care facility in Kirkland, a Seattle suburb. Within a few weeks, deaths of more than 30 other patients from this facility were linked to the virus. At this writing, Washington State has suffered more than 300 deaths from the COVID-19 and more seven thousand people have tested positive for the virus. And the toll mounts daily.

I live in Seattle, about five miles from the ill-fated suburban nursing home that became a sort of Petri dish for the new pandemic. As in most states now, all Washington citizens are now under orders from our governor, Jay Inslee, to “stay at home,” except for workers in essential businesses or to address medical and food needs. We’re fortunate in Washington State that Governor Inslee listened to public health experts and took immediate steps to “flatten the curve” and reduce virus deaths by ordering closure of nonessential businesses and encouraging simple health measures such as social distancing and hand washing. 

The pandemic has affected all of us in many different ways. I have a special interest in the history of medicine and I wanted to know more about past global pandemics and the story of this mysterious new virus, COVID-19. 

Luckily, I recently came across distinguished historian Professor Frank Snowden’s magisterial new history, Epidemics and Society: From the Black Death to the Present (Yale University Press). 

Professor Snowden’s sweeping chronicle of infectious disease epidemics over the past 700 years offers vivid descriptive accounts of diseases from bubonic plague, smallpox, and tuberculosis to malaria, polio, HIV/AIDS, SARS, Ebola, and more, and also details the transformation and evolution of societies ravaged by epidemics. 

His book is also a compassionate account that gives readers a sense of the human face of those who suffer and die from epidemic illnesses, as well as those who offer care for victims as they sacrifice their own health, and those who seek treatments and cures. And it’s a story of medical progress and setbacks as it offers a context for understanding the new coronavirus in this era of rapidly emerging diseases. And, the book is a testament to the importance of understanding history in preparing for epidemics and developing effective responses.

Frank M. Snowden is the Andrew Downey Orrick Professor Emeritus of History and History of Medicine at Yale University. His other books include The Conquest of Malaria: Italy, 1900–1962, and Naples in the Time of Cholera, 1884–1911. The Conquest was awarded the Gustav Ranis Prize from the MacMillan Center at Yale in 2007 as “the best book on an international topic by a member of the Yale Faculty,” the Helen and Howard R. Marraro Prize by the American Historical Association as the best work on Italy in any period, and the 2008 Welch Medal from the American Association for the History of Medicine. He received his doctorate from Oxford University.

Professor Snowden graciously talked with me by telephone from his home in Rome, Italy. We began by discussing the situation in Italy, which has been devastated by COVID-19. He also explained the coronavirus in detail and its historical context.

Robin Lindley: Congratulations Professor Snowden on your sweeping new book of medical history, Epidemics and Society. How are you doing in Rome? 

Professor Frank M. Snowden: I can't really complain. I'm doing as well as can be expected, but the circumstances aren't good for anyone at this point. But given that, things aren't too bad. Talk about yourself. I know Seattle also is having a terrible time. 

Robin Lindley: My wife Betsy and I are doing fine here. We are under Governor Jay Inslee’s order to stay at home, so we're staying in. We can go out for neighborhood walks but parks and other public gathering places are closed. Schools and non-essential business are closed. We went to a couple of grocery shopping hours for seniors, which are always a happening. The clerks eventually told us that these are the busiest times of day. So we’re well and safe so far. We have a governor who listens to public health experts, fortunately. 

Professor Frank M. Snowden: Yes. Jay Inslee is a wonderful governor. I was sorry he dropped out of the presidential race.

Robin Lindley: He’s a devoted environmentalist with strong views on the climate crisis. And he’s been an acknowledged leader in addressing this pandemic as national leadership has faltered. Each state now operates as a separate fiefdom, each one bidding against others for critical medical equipment. Governor Inslee has urged citizens to observe public health admonitions to stay well and protect others.

Professor Frank M. Snowden: Are some people defying the orders?

Robin Lindley: Most people we see are compliant and trying to observe physical distancing and other protocols. I sense that defiance isn’t a big problem, at least around Seattle area. How are you were doing and what's happening in Italy right now? 

Professor Frank M. Snowden: I’m doing well personally. Like everyone else in the country, I’m locked down at the moment and it sounds a bit more rigorous than in Seattle. No one is allowed outdoors unless you have what's regarded by the state as an essential job such as in healthcare. But for ordinary mortals, you are allowed outdoors only for the purpose of shopping for provisions or medications. In fact, it's hard to show up for anything else because almost everything else is closed. 

Therefore, while one can go out to shop for food, you must have an official document that you download that says your purpose for going outside and where you are planning to go to show if the police stop you. And if where you're actually found is different from where you said you would go, then you can be subject to a hefty fine. And the police are fairly frequently outside. You are not allowed to go for a walk or things like that. There's only the one purpose, and you're not allowed to meet anyone. You can't visit family members or even an elderly parent. All social gatherings are forbidden.

One learns a lot from observing. In fact, I've kept sort of a diary during these three weeks of a lockdown so far, partly on how it's affecting me as I think about it, but more importantly, what I observe as I walk around the neighborhood on my shopping outings, which is really all I can see. I have a very small view of the world because I can't leave this neighborhood, just like anyone else. But I do see changes in people's attitudes over time. 

I would say that nationally, this is from reading and not from any direct observation, it seems as though the rather stern lockdown has been mostly accepted by people for several reasons. One is that it is imposed by democratically-elected people who, citizens trust, will be held accountable. Furthermore, it’s temporary, and there's just one message. The state doesn't speak with multiple voices as seems to be happening with the United States government. In other words, in the Italian situation there isn't the chaos of a president, fifty governors, boards of education, and mayors all saying different things. There's just one policy and it's uniform over the entire country. 

And with that goes very careful messaging.  Everyone understands that the measures taken are essential, and that their purpose is to protect people. The message conveys the clear idea that a lockdown is only known way of dealing with the crisis. 

Another aspect of the government message is that you're not helpless. There are things that you can do -- by complying -- to protect yourself and everyone around you. And that’s a powerful message. We’ve learned that we're all in this together, and the government is saying that at every opportunity. And you can hear the result even in the lines waiting outside of shops, where people say things such as, “I wonder if this was what it was like in the world war?” People have made reference to the Blitz in London when everyone was in a very tightly regulated, confined situation, but there was a sense that everyone was in the same situation together. I found that quite moving. It’s important for leaders elsewhere to have the chance to observe that.

But people are quite worried and frightened.  That comes across as well. For example, in the building where I'm staying the super and I were chatting. I said, “Don't worry too much. One day, this too will be over.” He replied, “Let’s hope we’re still alive to see that day.” Clearly, he meant to be funny, with a sort of Australian gallows humor. But his comment also showed me the extent to which people really are frightened, and you can see that everywhere.

For example, when you go shopping and encounter someone in the street, even though you’re both wearing masks, are outdoors, and are widely separated, most of the time that person will actually go into the street and walk around the cars to avoid coming anywhere near you. That’s a clear sign. 

And I heard neighbors waiting in supermarket lines grumbling about other people in the supermarket who weren't wearing masks, even though they’re not at all easy to find these days. We are not short on toilet paper, but masks and gloves seem to be what Italians have stocked up on. Nevertheless, there are all people who are put out that others are being socially irresponsible. 

So that’s what I'm observing. But my sense that people are compliant was pointed out by the local newspaper Il Giornalein Rome, which had a comment that this is the first time in 3000 years of Roman history that the people of Rome have been obedient. That's a nice way of thinking about it.

Robin Lindley: I look forward to your diary Professor Snowden, if you publish that. Why do you think the COVID-19 positive cases and death toll are so high in Italy? There are more than 15,000 virus deaths in Italy now and more than 125,000 people there have tested positive for the virus.

Professor Frank M. Snowden: That's one of the puzzles of this epidemic here. There are some clues, but I can't answer your question fully. I can just make a couple of observations in passing. One is a paradox of Italian success, and that is to say its healthcare system has been very effective in prolonging life so that you can live several years more by being here than in the United States, for example. One of the consequences is that the most vulnerable cohort of people, the elderly people, actually live longer than almost anywhere in the world. So I think that's one factor. But that doesn’t explain the whole difference. 

  Some of the answer may have to deal with how statistics comparatively are collected during this epidemic. Comparative observations are often like comparing apples and pears because the data behind them are collected in such different ways. The number, the amount of testing, and its extent, also varies from country to country and from place to place in a country. But the calculation of the number of deaths is very reliable because the bodies of the dead are unmistakable. The denominator, however, is the number of cases and that is a moving target. For every country that figure is very, very unreliable. 

Therefore, the appearance of a high mortality in Italy is partly an artifact of how statistics are collected rather than of what's actually happening. But that’s a suspicion, and I can't actually prove it except to say that the numbers in every country, as everyone agrees, are very unreliable because not enough testing has been done almost anywhere except in a few places like South Korea and parts of Italy. The Italians have done a lot of tests, but it's actually hard to get a test, so I don't place a lot of faith in what the real denominator is here, or anywhere.

Robin Lindley: Have you had a test for COVID-19? 

Professor Frank M. Snowden: No. You would have a hard time getting the test at the moment because they are reserving them for people who have the classic symptoms. To get a test in Rome at the moment, you need to have a temperature and some difficulty breathing and a cough. Otherwise, it would be difficult to just request one. If I have a cough, it might be related to hay fever or something, and they would say, well let's monitor and see how this develops. I myself had a very slight temperature at one point.  I've been in contact with a physician and the temperature doesn't seem to be going anywhere. He told me that the health system would not see that as a valid reason to have the test.

 Robin Lindley: That's the same situation here. And there aren't a lot of tests available. I appreciate your book Epidemics and Society. It's very helpful in providing context for what we’re now experiencing with COVID-19. What is this new coronavirus and how did it originate?

Professor Frank M. Snowden: The novel coronavirus is present in wild animals, particularly in bats that are a reservoir for it. There are hundreds of species of bats, and some of them harbor the virus, although their immune system is such that they are actually not affected by it. It doesn't cause a bat disease. 

Part of the story of our globalized world is that we have this huge population, nearly eight billion people, with a common world economy that's constantly expanding. With that expansion, we are relentlessly devastating animal habitat, and the consequence is more and more encounters between people and wild animals than ever before. Polar bears are now found in Alaskan towns, and wild boars have become common in the streets of Barcelona. One can go on and on.

With regard to bats, a number of scientists have done studies and found that people in central China--in Wuhan--had been eating bats even before this became a human disease on a large scale, and there were spillover infections. Scientists discovered also that people had been in caves and they discovered the artifacts in terms of beer cans and other objects found in the caves.  They were able to discover a number of viruses and to identify the ways in which they spilled over from the bat population to humans. For the most part these encounters went unnoticed because they didn’t produce clusters of infection although testing demonstrated that there were people who had antibodies to the coronaviruses the scientists discovered. 

It also happens that people invade the areas where the bats live for extended periods and bring them and other wild animals to bushmeat markets to be sold for religious and medicinal purposes. Traditional Chinese medicine, for example, holds that various parts of these animals are health-giving and can be used as remedies to various maladies or conditions that people have. So there is a market for these animals, and their meat, being expensive, is a status symbol. 

The animals are taken to the wet markets in cages and butchered at the time of purchase in very unhygienic conditions such that their blood runs over everything as does water sloshing from fish tanks and other contaminants. Imagine a great warren of closely adjoined stalls with no hygienic regulations narrow passages jam-packed full of people like a large Petri dish. In Wuhan, the virus contaminated the environment of such a market. The coronavirus was actually found in the market, which wasn’t even closed down. Shoppers were infected and they took it home with them and spread it to their neighbors and families. So this disease began silently and unnoticed, and then spread in clusters through a very congested city. 

We can say that this virus was transmitted to people because of the way in which the human relationship with the environment and the habitat of animals has been transformed by our constant demographic and economic growth, taking over more and more areas of the planet and destroying biodiversity. So that's how the disease got to humans. 

Robin Lindley: Does climate change also play a role in the spread of the virus? 

Professor Frank M. Snowden: Yes, climate change also plays a role in this. One can see that particularly in vector-transmitted diseases because a world is being created that extends the area within which various insect vectors such as mosquitoes can thrive, and you have the spread of Zika, malaria, and dengue fever. Those are really important aspects of climate change. 

Climate change is definitely changing disease patterns and producing emerging diseases that human beings are vulnerable to. So that is a very important factor. With regard to coronavirus, it's not so clear that climate, as opposed to habitat, is the major issue. We don't know very much about this disease because it has been known to affect humans only since December. We’ll learn a lot more about it as we go forward.

Robin Lindley: How does coronavirus affect humans and eventually lead to their demise?

Professor Frank M. Snowden: There’s a lot of misinformation about coronavirus. It’s not transmitted in casual encounters. It’s not transmitted on an airplane by an infected person to people sitting several or more rows away. By comparison, smallpox and measles could be transmitted through the air in just that way.

At least one of the good things about coronavirus is that it transmits within a small radius of infectivity. And it tends to infect people not through transient contact, but through prolonged contact as would occur in a family group, a workplace, restaurant, bar, or school. I'm afraid we're going to see many more cases in prisons and other closed places. 

COVID-19 is spread through droplets when people cough, sneeze, or talk, sending sputum into the air. Then the virus borne by the droplets is then inhaled by people or it contaminates a surface that people later touch, contaminating the fingers that they then bring to their mouth, nose, and eyes.  In fact, as studies show that, in the course of an hour, a person normally touches his or her face many times, allowing the virus to find a portal into the body. That's a very common way in which this disease is transmitted. 

Once admitted to the body, the coronavirus doesn't cause an upper respiratory infection, but rather goes down very far down into the lungs.  In serious cases, it leads to pneumonia. Therefore, severe complications are oxygen hunger and breathing disorders that require ventilators and other respiratory support.  Patients who have those very severe symptoms suffer respiratory distress leading in turn to multiple organ failure. It's not at all -- as we've sometimes been told -- like the common cold or seasonal flu. COVID-19 is far more likely to lead to agonizing disease and death.

Robin Lindley: Isn't this coronavirus considered a form of SARS [Severe Acute Respiratory Syndrome]? That seems the closest analogy from your book. I was struck by the parallels in terms of Chinese concealment and how the SARS virus traveled in 2003. 

Professor Frank M. Snowden: Yes, indeed. COVID-19 is the disease and the coronavirus responsible is so similar genetically that it is termed SARS-V-2. 

SARS also began through a spillover from the animal world to people. And it seems to have originated in the same wet markets as the coronavirus. In fact, immediately after the end of the SARS outbreak, the Chinese authorities closed down these so-called wet markets. But then there was enormous push-back, and even authoritarian regimes often respond to popular pressure. The regime therefore yielded to popular sentiment in this matter and reopened the markets.

We need to remember that wet markets serve traditional Chinese medicine and folk beliefs such as the idea that eating wild meat makes you more robust and resistant to disease. At the same time, it's good for people who don't have refrigeration. Furthermore, since bush meat is expensive it’s a status symbol.

So these markets sprang up again, although the regime knew that they were a danger to public health. Today, there’s a lot of speculation about whether they’ll ever be reopened. But unfortunately, they were re-opened after SARS.

Robin Lindley: I don’t remember great public concern about SARS. Are there similarities between the progression of SARS in 2003 and what's happening with COVID-19? How did the SARS epidemic end? 

Professor Frank M. Snowden: As human beings, we dodged a bullet with SARS because SARS is not so very easily transmitted as COVID-19 is, and so it was possible to contain it. It reached a number of different countries, but then was then confined within hospital settings and didn't initiate community spread. SARS thus lasted just six months.

Both are pulmonary viral diseases, and SARS is more deadly. But it doesn't produce asymptomatic or presymptomatic carriers who shed virus in the way COVID-19 does, and it is therefore more readily detected.  The incubation period is also different, and SARS requires more prolonged contact. Although their genomes are close, they are quite distinct diseases and SARS is much less dangerous as a pandemic disease than COVID-19.

Robin Lindley: Thanks for explaining that Professor Snowden. I didn't realize the great difference in terms of transmission of SARS and coronavirus. I also wanted to ask about swine flu, the H1N1 virus that hit the United States in 2009 and caused about 12,000 deaths and about 60 million cases. Trump has mentioned swine flu and claimed that President Obama failed to respond. This administration also seemed to view swine flu as analogous to a COVID-19. What have you learned about swine flu? 

Professor Frank M. Snowden: I actually don't think that it was forthcoming of our president to say that Obama didn't respond and that this new virus is similar. They are two completely different diseases and they're transmitted in different ways. The way that they reach humans is very different. 

Although H1N1 affected a large number of people, it didn’t have anything like the impact COVID-19 is having and is likely to have because we're still at a fairly early stage in the spread and progression of the COVID-19. Unfortunately, it looks as though it's only beginning to ramp up in India, Africa, and Latin America. So I think we haven't at all seen the world spread of this and the total toll it’s going to take in human life and suffering. So the analogy with swine flu is a poor one.

The naming of that disease as the swine flu caused people in Egypt in particular to slaughter all their pigs, holding pigs responsible for the disease. That’s one of the reasons that WHO was very careful to appoint a commission of scientists to find a term for the virus that was scientifically solid and didn't point a finger at a particular group or ethnicity or geographical area or even animal groups such as pigs. The swine flu is an example of why they took so much care about that. 

Scientists are very upset with the decision of the present administration in the United States to insist now on names for coronavirus such as the Wuhan virus or the Chinese virus or the foreign virus. It strikes me that this is part of this administration’s refusal to take science seriously. Many leaders of today's Republican party don't accept the theory of evolution or climate science. All of that also goes together with a rejection of the term COVID-19. That has very serious implications in terms of the relationship of our world to science, to authority and to expertise. 

I worry that the science behind the term COVID-19 is not being accepted because the implications of not accepting it are first, the one that I mentioned regarding the rejection of science. But a further serious result is the rise of stigma against people of Asian origin all around the world. That's been one of the sad and often violent undertones of this outbreak. 

Pigs suffered under swine flu and people of Asian origin are suffering now by being stigmatized and discriminated against. There are attacks occurring as we speak in various parts of the world by people who are bigoted and don't even make distinctions between Korean, Vietnamese, Chinese or other Asian people. They lump them all together and discriminate against all people of Asian origin as if coronavirus were embedded in their DNA.

Robin Lindley: How does coronavirus compare to the influenza of the great pandemic from 1918 to 1919?          

Professor Frank M. Snowden: It was a pandemic of influenza that also affected the deep areas of the lungs. Most lethally, the immune system of the body of young adults generated a devastating autoimmune response. Unlike COVIOD, the 1918 influenza preferentially targeted people in their twenties, thirties, and forties. 

It seemed unnatural that the flu pandemic was not so severe the elderly or the very young. The elderly are partly immune-suppressed and children have immune systems that have not fully matured. The very robust immune responses of young adults instead produces what is called a cytokine storm that mobilizes blood and the white blood cells as an immediate defense against the virus that has invaded the lungs. Unfortunately, the impact of so robust an immune response is that the blood in the lungs actually causes the patient to drown  

That's part of the story. This Spanish influenza was more easily transmitted over distance, and it was also far more lethal than COVID-19. In some ways a first reaction is that we're fortunate that this isn't the Spanish influenza. On the other hand, we don’t know what the future will hold and whether COVID-19 will be contained or will instead ravage those countries of the developing world where you can't practice social distancing because of the density of housing, or hand washing because of the absence of supplies of safe water; where people's immune systems are already compromised by other morbidities, such diabetes, malaria or HIV/AIDS; and where resource-starved healthcare systems offer no protection.

South Africa has the largest number of people suffering from HIV/AIDS, an immune suppressive disease, so one can imagine that coronavirus could take a terrible toll in loss of life and suffering there, especially in the congested and impoverished townships. So the context matters a lot in determining how serious this pandemic is going to be.

Robin Lindley: You mentioned the fraught term “China virus” and the stigmatizing of Asian people. There have been some horrible incidents just in the last couple of days in the US with attacks on Asian-appearing families and even severe injuries to toddlers. From the history you share in your new book, it seems epidemics often lead to oppression and hate crimes. And you note that germ theory was a phenomenal scientific discovery, but it also led to stigmatizing of poor and dispossessed people. 

Professor Frank M. Snowden: Yes, indeed. Stigma is one of the red threads that run through the history of epidemic disease. 

 It would be inaccurate, however, to say all epidemic diseases have produced this sort of reaction in populations. We were just talking about the Spanish influenza that doesn't seem to have produced such reactions in a sustained or widespread manner.

We can't automatically assume that when there's a pandemic disease, there will be an outbreak of stigma to accompany it. But, beginning with bubonic plague [from the fourteenth century to the eighteenth], there have been such reactions. That was a time of great violence, stigma and witch-hunts for whoever might be deemed responsible for the disease.  There were waves of antisemitism. In Strasbourg, France, the two thousand Jews who lived there were rounded up and offered the choice between either converting to Christianity or being killed on the spot. Those who chose not to convert were burned alive in the Jewish cemetery. Similarly, as the Christian Flagellants whipped their way across Europe in their 40-day processions of repentance, they often projected their violence outward onto foreigners.

That's an important part of the history of bubonic plague. One can see it also in the work of Italian novelist Alessandro Manzoni who wrote a wonderful novel that's in part a plague novel called The Betrothed set in the 17th century when Milan was at war with Spain. As it happened, some helpless Spaniards having nothing to do with the war or espionage happened to be in Milan, and they were rounded up by local citizens and denounced for spreading the disease by smearing poisonous ointment on the doors of the city. The local authorities tried them and, under torture, they confessed. They then broke them on the wheel and then burnt them at the stake. The authorities also raised a column there to warn that in perpetuity, anyone who committed the same crime would experience a similar fate.

Blaming people has happened again and again. It happened with cholera. It certainly happened as we know with HIV/AIDS with the stigmatizing of homosexuals. This violence is not something that's new and it has accompanied many epidemic outbreaks over the course of many centuries. 

It's a very unhappy part of our psyche that so many people are tempted to look for an easy, nonrational explanation--that is to find a scapegoat. It has led to witch-hunts across the centuries, and that's a very regrettable part of our history. It's one of the reasons I think it's so unfortunate to call this the “Chinese virus,” which somehow legitimizes the reaction that Chinese people are somehow to blame for this virus. 

Robin Lindley: Yes. Some people with Asian physical features have paid a horrific price in recent weeks. I’d like to go back to the preparedness of the United States for the coronavirus now. This administration often has adopted divisive, antiscience and xenophobic positions that don’t bode well for addressing a global pandemic. Trump is also notorious for blaming Obama for every failing of his policies. However, the Obama administration had policies and people in place for dealing with pandemics, and those people and policies were abandoned by the current administration. How do you see US preparedness for this new pandemic?

Professor Frank M. Snowden: To me, one of the most disturbing questions posed during this pandemic thus far was the one our president raised when he asked “Who could have thought?” The answer to that is that everyone should have anticipated a pandemic challenge because, since the avian flu of 1997. public health authorities and epidemiologists have been saying that a pandemic – probably of a pulmonary virus -- is an inevitability and that it's only a question of when.

In 2005, when [infectious disease doctor] Anthony Fauci testified before the US Senate, he made an analogy with meteorological science. Climate scientists can warn people who live in the Caribbean with a certainty that they will experience hurricanes in their future. It's not a matter of whether but of when, although it’s impossible to predict the date or the force of the storm. But it will definitely come. The same, Fauci said, is true of epidemic diseases. We’re ever more vulnerable to pulmonary viral epidemics because of climate change, human population growth, the destruction of biodiversity and animal habitat, and the growing frequency of viral spillovers from the animal world. 

All of that is part of the globalized society that we've created and therefore the vulnerability and risks that we're facing. The idea of preparedness was raised consistently and loudly from 1997 onward. 

Preparedness is not simply a partisan issue. The Republican administration under George W. Bush developed a national plan for endemic disease that was published in 2005, and revised by 2007. It was followed on the global level by international health regulations making emerging diseases notifiable while the World Health Organization drew up an international, emergency plan. Similarly, departments of health in all 50 states of the US had their preparatory plans. Various major corporations also had plans in the event of a new pandemic threat internationally and to the United States. 

Under Presidents Bush and Obama, the United States launched the President's Malaria Initiative, a massive campaign to combat malaria in Africa, and parallel efforts against tuberculosis and HIV/AIDS. Within the National Security Council, they also appointed a council to advise the government on how best to counter the threat of an epidemic challenge that was known to be coming. 

It was a tragic that Trump fired Admiral Ziemer, the head of the council, and dismantled the whole organization that he led. It's also poignant that in 2018, the World Health Organization appointed a distinguished commission of international scientists headed by the former prime minister of Norway, herself a major scientific figure. In 2019, in its report entitled “A World at Risk,” the commission warned of another pandemic. That was the most recent of warnings that had been sounded constantly for nearly a quarter of a century.

So, to have the president of the world's most powerful nation ask, “Who could have known?” is profoundly distressing because that's something that the whole world of science knew. That's also why I was so upset by the failure of the administration to use the term COVID-19. By insisting on “Chinese virus,” the president demonstrates a blatant contempt for science and its arguments. It's in that context that the administration slashed the budgets for public health and for scientific research; stood down the sentinels; and discarded the structures on which our security depends. But such an approach did not happen in the United States alone. Other countries have done just the same. In Italy, for example, the Five Star Movement has consistently denigrated science, while the Italian government has savagely cut the funding for its health care system and for research. The budgets for the World Health Organization were also slashed. 

The point is, we didn't need to be so unprepared for this event. It was predicted. The tragedy is that the world turned a deaf ear to the warnings of scientists. In this way a quarter of a century of advance notice was squandered. That’s a central part of why we are where we are today. 

Robin Lindley:  What are the responses to pandemics that you’d like to see the US and other nations employ? 

Professor Frank M. Snowden: I’d mention two interesting little statements. One was from a doctor in Toronto on the front line against SARS in Toronto. When that pandemic was over, he was asked what needed to happen, so it would never recur. He replied, “We must be forever changed.” Similarly Bruce Aylward, the Canadian epidemiologist who led the WHO mission to China, was asked what is required for our preparedness. He said, “What is required is that we have to change our mindset.”  What he meant was we must change our hearts and minds.  

As Dr. Tetros, the Director General of the WHO said, one of the requirements of preparedness is that every human being on the planet needs to have the guarantee of access to health care. It’s not just a humanitarian issue, but also an issue of enlightened self-interest because we've now created a genuinely global world where a virus appearing in Jakarta in the morning will land in Mexico City and San Francisco by nightfall. And  having access to healthcare is actually what it means to post sentinels. If people don't have access to a doctor because there are none, or the cost is prohibitive, or they're afraid to see a doctor because of stigma, then diseases can spread without anybody’s knowing. That's one of the great lessons to be learned from COVID-19.

It’s also prudent economically and fiscally prudent to establish universal access because dealing on an emergency basis with recurring challenges is the most expensive possible way of protecting public health. During the Ebola epidemic of 2014-2016, the cost of fighting Ebola on an emergency basis exceeded severalfold the cost of establishing sustainable health systems in the three countries of West Africa that were struggling with the disease. Once established, those systems would have helped to promote health in multiple additional ways.

So it’s economically prudent and I think we'll see that the final cost of the coronavirus will be enormous and that it will disrupt the economy for a long, long time. It seems clear that it would have been far more cost effective as well as more humane to have had health care for everyone on earth. That would be my first point. 

We also have to recognize that a major driver of this disease is poverty. Millions of people can't afford to see a doctor, to practice social distancing, or to wash their hands frequently.  One need only think of the chawls of Mumbai, the townships of South Africa, or the favelas of Rio de Janeiro. There are many places so crowded that people live with nine or ten people to a small room with no water supply. If they are locked down, people face starvation. 

Thus, the relationship of the industrial world to the emerging world is a very dangerous one in terms of health. We see now the large-scale flight of the capital from the third world with a devaluing of currencies with the result that goods and services essential to life are prohibitively expensive. Already, in large parts of the world, mothers are watering down the milk for their children because costs have suddenly shot up. In addition, the disappearance of tourism and investment means that people throughout the third world will be deprived of the necessities of life and that the world will suffer a massive surge in unemployment will further drive the pandemic. 

The world needs to realize, as Bruce Aylward said and as Dr. Tetros has been saying daily during, we really are all in this together. This virus is a disease of globalization and we must realize that microbes don't recognize borders. They don't make a distinction between the wealthy parts of the world and the impoverished parts of the world. And you cannot create walls to hold them out. 

Taking this global perspective, carefully funding the World Health Organization is a major part of our preparedness. Indeed, that's part of how we need to be changed forever after this experience. Just as important as dealing with this pandemic is the question:  once it is successfully contained, what are we going to do? What are our priorities for the future? 

This isn't the last microbial challenge, but the point about these challenges is they don't have to devastate us. There are things we can do to protect ourselves. One of those I didn't mention is directing scientific research. It is possible to develop vaccine platforms that are multivalent. That could have been in place with seasonal influenza vaccine platforms that could quickly generate a vaccine against, coronaviruses as a class. But that hasn't been done. We weren't developing and investing in the tools that medical science could provide us if we funded it in sustainable ways. That also needs to be done. 

Robin Lindley: Thank you for sharing those ideas on preparedness, Professor Snowden. I’m interested in your background. You’re one of America’s foremost scholars on the history of medicine. How did you decide to specialize in the history of medicine? Did you have a medical background? 

Professor Frank M. Snowden: The history of medicine is something that I hadn't anticipated doing, and I've been doing it now for 40 years

I believe two things got me into it. I studied political philosophy for my undergraduate degree. Then, in my doctoral work, I transitioned to becoming a historian. I started with political and social history and then discovered the field of history of medicine as I did broader reading on disease and health. 

I found that pandemics are looking glasses that reflect us back to ourselves. Why? Because these pandemics touch every area of the human psyche. They deal with such fundamental issues -- philosophical, religious, and moral. They touch our deepest anxieties and pose the question of the sudden death of our families, our children, our communities, and ourselves. They raise the question of our relationship with our deepest beliefs. Do we believe in a divinity that is all powerful, omniscient, and knowing, and yet created a world where, as with the Black Death, children were killed en masse? So people wrestle with their religious beliefs in times of epidemics. 

And, as we're seeing with coronavirus, pandemics devastate the economy, generating all sorts of anxieties about employment, about hunger, about one’s savings, about one's capacity to care for loved ones. 

All of these questions are thrown up. And what about political authorities? Do we trust them? Are they protecting us? All of those kinds of questions are raised by epidemic diseases. I found them a tremendous way of understanding how societies are put together, what their ultimate values and their moral and political commitments are. 

And I believe that epidemics are major parts of the big picture of historical change. Let's not say that they should replace economics, nor should they replace other factors such as environmental ones and a host of others. I'm not saying that studying epidemics should replace them, but they need to be an essential part of the historian’s craft. 

I decided to study epidemics in a really big picture away, and I took on the fall of the Roman empire. The fifth century was a time when there was major climate change in the Mediterranean and it was also a seismic and volcanic period, and with that a surge in mosquito populations. You see in the Italian peninsula a major series of epidemics of the worst form of malaria, falciparum malaria, that has been demonstrated by the DNA analysis of teeth from fifth-century burial sites. Malaria epidemics were also demonstrated archeologically by the abandonment of towns and villas during this period as malaria extended its reach. That led to the dislocation of agriculture and the economy, to the crisis of the economy, and to the weakening of the Roman legions. So that was a major factor in the fifth century, and then in the sixth century there was the Justinian plague. 

I would argue that in the future it won't be possible to deal with the fall of the Roman empire without invoking the major impact of disease. There are many, many other examples, but I just thought that the fall of Rome would help make the point. 

Robin Lindley: You’ve studied some of the most horrendous catastrophes in human history. What gives you hope now as we face a mysterious new pandemic in a time of anxiety and uncertainty?

Professor Frank M. Snowden: If I thought that the history of infectious diseases was exclusively a study of disaster and despair, I would long ago have abandoned the subject as unbearably depressing. Fortunately, however, along with the dark sides of human nature, epidemics also demonstrate our brighter and more hopeful qualities. One can see that again and again in the heroism of physicians, nurses, and caregivers; in the dedication and ingenuity of medical scientists; and in the slow, but steady advance of the science of public health and hygiene. 

That history fills me with the hope that we will, in the end, survive COVID-19, and with that experience behind us, we will resolve to organize our society in such a way that we are not again scourged by a deadly pandemic.

Robin Lindley: Thank you Professor Snowden for your thoughtful insights and timely discussion of the mysterious virus we now face. And congratulations on your sweeping new history, Epidemics and Society. It’s been a pleasure talking with you. Stay safe and well in Rome.

Robin Lindley is a Seattle-based writer and attorney. He is features editor for the History News Network (hnn.us), and his work also has appeared in Writer’s Chronicle, Crosscut, Documentary, NW Lawyer, Real Change, Huffington Post, Bill Moyers.com, Salon.com, and more. He has a special interest in the history of visual imagery, medicine, law, human rights and conflict. He can be reached by email: robinlindley@gmail.com.