The other day, on 24 February 2020, President Cyril Ramaphosa’s weekly letter to South Africans focused on building support for the proposed National Health Insurance (NHI). Drawing on the country’s history to make his case for finally addressing the centuries-long inequalities in health care, he (or perhaps his ghostwriter) fastened on to the smallpox epidemic in the Cape in 1713 as an example of the deep roots of such unequal treatment.

Ramaphosa wrote, “Our past has taught us that we must never be a country that promotes the interests of the few at the expense of the majority. In 1713 the Dutch colonialists who had brought a smallpox epidemic to our shores imported medicines from Batavia to treat those affected. They used the medicine to treat their own, leaving the indigenous Khoisan to be decimated by the outbreak.”

The problem with this reading of the historical record is an assumption that in tandem with growing racialism towards the aboriginal inhabitants of the Cape, the colonists actually had cures and treatments for smallpox, but on racial grounds, they had refused to share their lifesaving medicines with the indigenous population. 

The presidential charge sheet was arguing that the colonists had been able to import life-saving drugs from the Dutch settlement of Batavia (modern-day Jakarta, Indonesia) in time to deal with the disease, but only for themselves. Meanwhile, the indigene communities were suffering horrifically from the disease. It killed many and triggered desperate migrations of survivors into the interior, further spreading the disease, and contributing to the virtual dissolution of numerous Khoi clans and communities across the Cape.

There are, however, flaws with the president’s interpretation. First, of course, was that the epidemic killed many of the settlers as well as many members of the indigenous population. Moreover, there were in fact no medicines that could treat or cure the disease. Further, it would have been virtually impossible to get anything in short order from Batavia at the time, not when ship passages between the Far East and the Cape were measured in months – even if there had been appropriate treatments available to share. (No Amazon, no Takealot, no Alibaba would have been available to deliver it of course, even if it had existed.)

In truth, the vector for bringing smallpox to the Cape had been via already-infected crews on ships stopping at that small colony at the foot of the continent. It is true the colonists sent appeals to the East Indies by ship – for supplies of foodstuffs to keep the colony alive – but there were no magic bullets. In fact, although international health organisations have declared that naturally occurring smallpox has been defeated globally (outside of small samples preserved in specially designated, high-security laboratories) since the late 1970s, no effective cure has ever been developed to combat it.

About the only thing people acting as medical personnel back in 1713 were likely to have prescribed would have been bleeding to drain out all those presumably dangerous humours, per the best medical knowledge of the day. (Such treatments generally had a dubious utility, sometimes weakening patients so much they died from a loss of blood, as with George Washington in 1799.)

Actually, of course, even the best-trained doctors had no idea where smallpox came from, what it actually was, or how it spread. True, people had learned that a technique called variolation could render people less susceptible to the disease. But since that involved taking pus from a sore on the body of an active victim, and putting it under the skin of another, still-healthy person, there were risks, not least from helping spread the disease further by infecting still-healthy people.

It was not until nearly 100 years after that 1713 plague that English doctor Edward Jenner had worked out that because milkmaids in England were less likely to catch smallpox than the general population, having already been exposed to the related but less potent disease of cowpox, injecting people with stuff from a cowpox lesion might help ward off the much nastier disease of smallpox. But there was still no understanding of the germ theory of disease, let alone any understanding of the actual transmission mechanisms, or how not-yet-discovered germs caused disease.

This little excursion into South African historical epidemiology, triggered by Ramaphosa’s weekly letter, leads us to reach back further into the past, to the outbreak of the Black Death of 1357, and then to contemplate how such earlier experiences should inform our current global preoccupation with the newly encountered coronavirus or Covid-19 as it is now officially named. These, in turn, should encourage some sombre thoughts about the possible global impact of this virus.

What these three occurrences (and many other epidemics and pandemics historically) have in common is that transportation and trade have been the mechanisms by which the disease has spread outward from its original reservoir to reach many more people. That is even more important now than in the past.

The Black Death, generally thought to have been a particularly virulent strain of the bacteria causing bubonic fever, is understood to have reached Western Europe through a terminus of the trading networks of the Silk Road at the Black Sea port of Kerch. (Kerch was also the scene for major fighting in World War II as the Red Army was ejecting the German Wehrmacht from the Crimean Peninsula and Ukraine.)

In the 14th century, Kerch was a Genoan trading outpost, transhipping spices and essentials like pepper, furs, silks, and grain. In 1347, one particular Genoan ship left the harbour, presumably infested with rats that were hosts to the fleas which were themselves the hosts of the bacterium that caused the disease. Sailing westward through the Dardanelles and across the Mediterranean Sea, this ship eventually docked in Genoa, then the seat of a commercial empire that included islands like Corsica as well as far-flung trading posts such as Kerch.

The disease took its time to spread along all the trade, pilgrimage and transhumance routes, but within a few years, it had reached virtually the entirety of Europe and much of the Middle East and North Africa, before killing what is estimated to have been somewhere between a third and a half of Europe’s entire population. It was one of the most devastating pandemics in human history, resulting in the deaths of an estimated 75- to 200 million people across Eurasia. The bacterium Yersinia pestis, which results in several forms of plague, is believed to have been the culprit.

In many places, as labour became so scarce, as serfs and other indentured labourers died from the plague along with everybody else, the Black Death is even “credited” with encouraging the end of feudalism in Western Europe. Populations less affected, such as some Jewish communities, were hit by pogroms based on rumours they had poisoned the wells, causing the plague. In parts of Europe, some cities took centuries to again reach pre-plague population levels.

Our modern circumstances are obviously quite different from those of the 14th century. But in a supercharged version of that long-ago plague’s distribution, the much more rapid diffusion of the newly identified Covid-19 is now tracing our global travel and trade routes. Its spread from the initial outbreak and identification in Wuhan, China just a few months ago, has followed the networks of international air travel routes and holiday cruise ships. First identified in East Asia, victims have now been identified on every continent, save Antarctica.

What public health officials and virologists most fear, of course, is the disease’s movement from its original spread by way of contagion contact with presumed mammal hosts in specialised Chinese food markets direct to consumers, on to direct people-to-people transmission, but then, most worryingly, the third stage with its spread into general populations – community-spread – not previously in contact with the original disease vectors.

Once that happens, tracing its actual vectors largely becomes much, much more difficult. And control by limited quarantine becomes that much more difficult as well. It is really hard in most societies to sequester an entire province or state, unless that society is an effectively controlled authoritarian one such as China.

Once things reach that point, dealing with the coronavirus becomes a race between further broad, widespread contagion and the development of effective cures or effective prevention via a successful vaccination. Neither is available now, despite all those internet rumours of secret cures or plots by evil drug companies eager to suppress cures or treatment for ill-gotten gains. Fortunately for humans, this virus, unlike smallpox or the Black Death appears to kill only a small percentage of its victims, at least until it possibly mutates into a more virulent strain. Viruses can do that sometimes.

Global health authorities closely monitoring the disease’s spread have declined to label this a pandemic at this point. However, they are now professing ever greater concern for the possibilities of new concentrations of victims around the world springing up such as in towns in Lombardy in northern Italy or Daegu, South Korea (including Korean and US military bases), than in China. In common with earlier plagues, however, the impact of this disease on economics and finance is growing.

Stock exchanges globally are falling into market correction territory, and the prices of transportation, energy, and related shares are falling sharply. But still more important is the growing potential for real disruptions in global manufacturing and the consequent dire impact on economic growth.

In recent years, the explosive growth of thousands of Chinese firms as crucial parts of global supply chains now means that the growing disruption of China’s transport networks and labour movements due to virus containment measures will lead to manufacturers globally running into shortages of component parts for their own assembly lines – as well as shortages of products largely manufactured in China for foreign firms. Not surprisingly, such developments will, in turn, have negative impacts on global demand for primary commodities such as those exported by South Africa. Not good, that.

And that leads to a final point. Measures to deal with the spread of Covid-19 are quickly gathering speed in many countries (even if US President Donald Trump has continued to pooh-pooh the spread of the disease, and only grudgingly agreed to assign his vice-president as a kind of coronavirus czar). For example, Japan has now closed all of its schools and banned sports events for two weeks and Saudi Arabia has just banned foreign travel into the nation. Nonetheless, there appears to be little in the way of pan-African coordination.

As the BBC noted last week, “The World Health Organisation (WHO) has already declared the coronavirus outbreak a global health emergency – largely because of fears that poorer countries may not be able to cope with an outbreak.

“‘The main reason for this declaration is not what is happening in China but what is happening in other countries. Our greatest concern is the potential for the virus to spread to countries with weaker health systems,’ said WHO chief Tedros Adhanom Ghebreyesus, who is from Ethiopia.

“The health systems in many African countries are already struggling with the existing workload, so can they deal with another outbreak of a highly infectious disease?

“Michael Yao, WHO’s head of emergency operations in Africa, notes that some countries on the continent ‘have the minimum to start with – they’re not starting from scratch’.

“‘We know how fragile the health system is on the African continent and these systems are already overwhelmed by many ongoing disease outbreaks, so for us it is critical to detect earlier so that we can prevent the spread.’”

One underlying problem is that drawing scarce public health resources towards this new threat and away from other pressing needs can actually make the overall health of a nation even more precarious.

Accordingly, as Yao worries, given his experience with Ebola in West Africa in 2014-2016, and more recently in the east of the Democratic Republic of Congo, he was concerned there was insufficient capacity to treat critical cases of coronavirus. As he said, “We’re advising countries to at least detect cases early to avoid spreading the new virus within the community – that will be difficult to manage.”

Still, there are some positives. Various African countries were already screening passengers arriving at their ports of entry for Ebola, and countries that dealt with the Ebola outbreak still have the isolation facilities and expertise in controlling infectious diseases. But this new virus is different to Ebola, which only becomes infectious when symptoms present themselves. Instead, there are reports that in some cases with this new virus, transmission may have taken place before patients were showing symptoms.

Covid-19 is not quite poised to upend civilisation as the Black Death did, but it is going to be a really rocky time for many economies – not to mention all the people who come down with the disease. DM