Norovirus and the reporting of epidemics through history

This winter has already witnessed an unprecedented increase in cases of Norovirus – the so-called ‘winter vomiting bug’. For some reason, across the globe, the infection has spread with increasing virulence and also lingered longer than normal in parts of the world now moving from spring to summer.  Norovirus is an especially durable and adaptable virus. It is perfectly suited to what it does; spreading from person to person either through airborne contact with minute particles of vomit, or through surface contact with the virus…on some surfaces it can last for up to two weeks. Given that I have a pathological phobia of vomiting, this one is the stuff of nightmares!

In Britain, the Health Protection Agency is the public face of public health and is charged with providing a virtual barometer of sickness. Their website contains a list of the current maladies doing the rounds and, in the case of flu and norovirus, weekly updates on the numbers of the stricken. The site also contains tips on how to prevent the spread of the virus and some advice (if little comfort) to those who have already succumbed.

To my mind, the information on the HPA website is extremely reminiscent of the information disseminated to the public in past times of epidemic disease – say the seventeenth-century plagues. It strikes me that authorities throughout history have had to balance the need to provide practical details of encroaching sickness with the need to avoid spreading panic. The language of sickness reporting in fact has a long history, and show remarkably similar patterns.

The reporting of the numbers of sufferers, for example, is something that was certainly an important element in the way the Great Plague of 1665 was reported. In seventeenth-century London, the so-called ‘Bills of Mortality’ gave a weekly update on deaths in the city, in the form of a published pamphlet. Information for these pamphlets was gleaned from the ‘searchers of the dead’ – people (often women) who were employed to examine fresh corpses to discern the cause of their demise. Their diagnoses were diverse. In one bill dating from 1629, the causes range from predictable conditions such as measles, cold and cough and gout to other, stranger, ones such as ‘teeth and worms’, ‘excessive drinking’ and ‘suddenly’!

As the plague increased though, the Bills of Mortality became rapidly dominated by these numbers, and Londoners pored over the pages every week to gauge the seriousness of the situation. News of the contagion was a regular topic of conversation and people were eager to learn if things were getting better or worse. The newly burgeoning cheap presses of the mid seventeenth century went into action, with everything from treatises on the causes of the plague to ‘strange newes’ about the latest outbreaks or figures and even popular cures.

The authorities were clearly worried about the danger of epidemic sickness, and took measures to try and limit its spread. One of these was to try and restrict popular gatherings such as fairs, to try and prevent the disease running rampant. This Royal proclamation from 1637, for example, entreated people not to attend the popular Sturbridge Fair that year, the king ‘Forseeing the danger that might arise to his subjects in generall”.

So, the authorities published the numbers of sufferers, took preventative measures against the spread of contagion and, in general, maintained a dialogue with the public, updating them on disease types, currency and potential ways to avoid them. The popular press also served to stir up fears, however, and perpetuated public dialogue about infection. Disease and health have always been topics of conversation but, in times of contagion, they tend to become more concentrated, and people become more engaged in dialogue about them.

Fast forward to 2013 and it is remarkable how similar the situation still is. The HPA website, for example, gives a weekly update on numbers of norovirus sufferers, not only in terms of clinically-reported cases, but of an assumption that for every reported case there are a further 288 or so unreported cases – people who simply decide to stay home and self-medicate. Indeed, at the present time, people are being actively discouraged from attending doctors’ surgeries, and hospital wards are being closed to the public. The impression is one of a wave of contagion breaking over the British Isles and, for me at least, one that is coming to get me!

There is indeed a fine line to tread between reporting facts and sparking panic. When SARS first emerged, there was a great deal of information (and misinformation), with various ‘experts’ calling it variously a massive threat to humanity, or simply the latest in the processional line of epidemics to afflict humankind.  A few years ago, a virtual global panic was instigated by the apparent mutation of avian flu, or bird flu. This outbreak made ‘pandemic’ the buzzword of the late 2000s and, again, much space was devoted (and indeed still is to some degree) on educating people on what it is, who has got it, and how to avoid it. In 2005, a UN health official warned that bird flu was capable of killing 150 million people worldwide. According to Dr David Nabarro, speaking to the BBC at the time “”It’s like a combination of global warming and HIV/Aids 10 times faster than it’s running at the moment,”. The World Health Organization, perhaps seeing the potential panic that this could cause, immediately distanced itself from the comment. The fact that the outbreak was ultimately relatively mild emphasises the problem that epidemic disease causes for health officials. How to alert people without scaring them?

None of this is helped by the press who, like their seventeenth-century counterparts, are keen to give the largest mortality figures, or emphasize the spread of diseases. In June 2012, for example, Reuters were still warning that a global bird flu pandemic could happen at any moment.  http://www.reuters.com/article/2012/06/21/us-birdflu-pandemic-potential-idUSBRE85K1ES20120621

The same pattern is now happening with the norovirus – although clearly this does not carry the same levels of danger. Here we are talking about contagion, rather than mortality.  Let’s take the headline on the Western Mail newspaper of 20^th December though: “Norovirus: Now more wards are closing as hospitals in Wales hit”. The breathy style of this banner line emphasises its rapidity, not just a straight report, “NOW” it’s coming. What purpose do these reports ultimately serve? Put another way, why do we need to be told? Logically, if preventative measures are possible then it makes sense to tell as many people as possible. But often this is not the purpose of newspaper copy in times of sickness which, to me, almost seems at times to be deliberately provocative.

The answer seems to be a deeply-set human interest in sickness, ultimately linked to our own mortality. Even in this apparently scientific and modern age of medicine, there are still many things which are incurable, and many diseases which have the ability to wipe us out at a stroke. It is this uncomfortable reality which perhaps continues to fascinate and frighten us. We live in an age of control, but some things are still beyond our control, and it is perhaps this innate fear of disease – of our own transience – which makes these headlines ultimately so compelling.

The NHS Bill – an historical perspective.

At the very least, the NHS Bill is provoking lively and vigorous debate. Just the other week, the proposed legislation was referred to by Ed Milliband as “David Cameron’s Poll Tax”! Objections against the changes put forward are too many and too wide-ranging to explore in detail here. But, succinctly, the main bone of contention lies in the expansion of outsourcing of NHS services to private companies – in effect the privatisation (‘modernisation’ some prefer) of the NHS – and its possible effects upon the quality and cost of patient care in England. But just what is it about privatisation in the bill that worries people?

Privatisation is certainly a loaded term; for some it carries the implicit assumption that something will be lost in the process– that things could get worse for consumers rather than better. Are we even somehow resentful of the loss or degradation of our once-proud institutions like the post office and the NHS? Given that the latter only dates from 1948, this seems less likely although there is certainly a residual fondness for what has been, for the most part, a success story of public health.

It is worth considering the provision of healthcare in Britain in the past, and especially in terms of the question of private enterprise. Four hundred years ago, the concept of public healthcare simply did not exist – this was the original ‘medical marketplace’. How, then, did this manifest itself in the sickness experiences of our forebears? How did these proto-consumers of healthcare cope with this situation, and what types of medicine and practitioner were available to them? What, ultimately, can we learn from them?

The early modern period was characterised by a diversity of medical service providers. These included university-trained and licensed physicians who often catered for wealthy clients, and who were largely based in large towns and cities. Surgery was a separate branch of medicine, while apothecaries, although nominally banned from doing so, also provided medical advice as well as remedies and ingredients as they were more accessible and more affordable for many people. At a local level were an undifferentiated mass of medical practitioners, ranging from specialists, such as occulists, bonesetters and wart-charmers, to travelling ‘doctors’ who would claim to cure anything from toothache to the ‘itch’ for a few pennies. Even the local blacksmith could be called upon to knock out a rotten tooth.

This was a true consumer market with a massive variety of choices for the early modern patient.  Most people self-medicated. Some grew their own herbs, but many remedies and ingredients were available locally, even in rural villages. Surprising as it might sound, given our perceptions of contemporary living conditions, maintaining a healthy lifestyle was also important. People invested in healthy ‘regimens’ – daily steps to staying fit from fresh air and exercise to early modern equivalents of the tonic or health drink.

So if medicine in the early modern period was fully private, was it better? Clearly, conditions in the seventeenth-century differ markedly from that which the proposed NHS bill would create. In effect, this aims to drive down costs by putting more services out to tender giving the customer – the patient – access to care through different providers but still essentially free at the point of delivery. The early modern marketplace though, was patchy and uneven, with the availability of care and cure varyying widely geographically, demographically and economically. In terms of public health, for example, authorities might intervene to contain epidemic outbreaks, but this did not generally extend to treatment or tangible support for the afflicted.

The closest thing to ‘official’ medical support could be found in local parish poor relief funds. Here the parish might pay for the treatment of a sick parishioner, sometimes even paying for them to travel if the most appropriate specialist was not nearby. Friends or neighbours might also be employed by the parish to care for a sick person. This phenomenon actually resonates with current questions surrounding the boundaries of public care provision. In very recent times, for example, the language of deserving/undeserving has returned to political discussions about welfare provision – a terminology very familiar to our forebears. Could a similar scaling back as that mooted for things like housing or child benefit eventually affect the willingness of the state to fund certain lifestyle-related conditions, say through smoking, binge-drinking or overeating?

Turning the question around, are things actually better now? Free healthcare, massively more effective drugs and treatments and a similar diversity of practitioners suggest so, but stories about people extracting their own teeth as they could neither find an NHS dentist to take them on, nor afford private care, are reminders of the failures that can still exist. According to a recent survey in a popular newspaper, four in ten adults consider dental care a luxury, while the cost of prescriptions in England is set to rise in April 2012.

Nonetheless, it is worth noting that we already engage widely with a private medical market. Like our early modern counterparts, we are vigorous self-medicators. The first recourse for many of us is the chemist (the local apothecary) where we purchase over-the-counter palliatives, despite the option of a cheaper prescription. Many visit private practitioners such as medical herbalists, whether professionals or one of the increasing number of high-street outlets.  Also, the option to purchase bespoke treatment remains a way to bypass waiting lists and, dare I say it, get a ‘better’ service, perhaps in more comfortable surroundings. ‘Lifestyle’ in the form of health food and drinks, spa treatments and even private gym memberships attest to our continuing desire to stay healthy and try and fend off illness before it arrives – a sentiment very familiar to those in the seventeenth-century. This is a market worth billions.

So to raise the question again, what are we afraid of? There is already, as these examples suggest, a broad acceptance of the idea of private enterprise in medicine. Whether alternative therapies, such as high-street herbalists, should be banned hasn’t really been debated. Whether they should be available on the NHS has. The potential problem with the intervention of the private sector, and here the experience of the early modern period does bear relevance, is the potential risk of uneven quality of care. People across the country in the seventeenth century faced widely varying quality in medical provision, based not only on their ability to pay, but on the lack of centralised training or regulation. The NHS provides a safety net that people in the past simply didn’t have. The danger in throwing the doors open to different companies, say in parallel to the privatisation of rail services, is that quality will again vary regionally and demographically; rather than having consistent levels of services across the whole country, and for people at all levels of society, patients’ care will suffer. This is something that the government will have to think carefully about. Things were not always better in the past.