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What if we were living through the Black Death?

Modern medicine has come a long way but antibiotic resistance threatens to be a big step back

Living during COVID-19 feels simultaneously lucky and unlucky. Unlucky because we are social distancing and in the midst of a major global crisis. Lucky because it could be way worse. Thinking about the plagues of the past and what health systems use to be like makes being locked up with Netflix seem not so bad. This article considers how far health systems have come and antibiotic resistance. The purpose is not to put COVID-19 in perspective, but to illustrate the success of medical innovation and the consequences of regressing if we aren't careful over issues like antibiotic resistance and vaccine hesitancy.

The Black Death (bubonic plague) in the mid-14th century was the most deadly plague in human history wiping out millions of people across Europe, Asia and Africa. Symptoms included fever, joint pain, nausea and oozing sores among other things. It was likely spread by fleas and rats carried in merchant ships. We hope coronavirus will be largely managed with a vaccine by the end of 2021. The Black Death lasted for about seven years and changed the course of human history having various social and economic effects. Nowadays we can treat bubonic plague with a simple course of antibiotics.

Medicine and healing have come a long way since then. Hygiene wasn't well understood in the 14th century and there wasn't the technology or infrastructure to maintain cleanliness anyway without running water or proper drains. Cities were dirty places where germs and rats could thrive. Proper knowledge of how to stop transmission of the plague didn't exist, let alone cure it. Doctors tried to treat the Black Death with onions. Good luck to the sick.

Black death plague doctor visiting houses

We take modern medicine for granted

Long-life is a modern phenomenon that has changed our perceptions about what an acceptable length of life is. Not so long ago life expectancy was about half of what we expect today. In the 1800s, life expectancy was about 30-35. Today, 75 isn't that old in some parts of the world. Developments like antibiotics have added years to our lives as we can now fight diseases caused by bacteria. Diseases like smallpox, polio and measles use to have devastating health impacts, not so much today. Polio case numbers for instance have decreased by 99% since 1988 to about 30 or so cases today. Nowadays those diseases are largely controlled by vaccines, provided people actually take them. Modern medicine has been instrumental in this transformation in our life expectancies.

We take these developments for granted. It is expected that we will be able to combat most ailments, and medicine will keep evolving to address new diseases.

Yet germs evolve too. Antibiotic resistance presents a threat that could set health systems back centuries if we aren't careful. Germs learn to defeat the drugs used to treat them, and we aren't necessarily helping matters. Overuse of antibiotics on farms to treat disease, overprescription in unnecessary situations, and patients stopping treatment early have contributed significantly to growing antibiotic resistance. The Black Death may not return but we would be setting ourselves and our health systems up for failure.

What if antibiotics stopped working? According to the World Health Organisation (WHO), 700,000 people a year currently die due to antibiotic resistance. That figure could reach 10 million by 2050. That's a lot of lost life. If we don't address this issue, common infections could become lethal. The intergenerational equity issues attached to this are tremendous. Current and past societies are passing superbugs to the future.

Vaccine hesitancy presents a different threat - one of 'devolution' if people choose to skip standard vaccinations. Diseases from the past could come back in earnest if not enough people are vaccinated. There has been a 30% increase in measles cases worldwide. That is a threat both to the people who aren't vaccinated, but also for people who are vaccine resistant, that is, vaccines don't work for them.

COVID-19 is a rude awakening that medical development is still somewhat reactive

Pandemics can change the shape of society. The Black Death wiped out tens of millions of people. Wages rose due to the labour shortage. Land values declined in response to the population decline. Food prices fell. COVID-19 isn't in the same league as the Black Death, but the economic impact is still pretty bad.

The COVID-19 economic and health impacts are still unfolding with stagnating economies and about a million deaths as of the time of writing. More interesting are the long term effects we will see as COVID-19 shakes society into new social and cultural norms. The increase in working from home could become permanent as people decide that actually, it's quite nice getting an extra hour's sleep. If we work more from home maybe it isn't so important to live in the city and prices in central suburbs fall. Commutes could reduce with less investment needed for infrastructure as motorways become less important. Perhaps there will be more opportunities to live and play outside of cities. Who knows?

The race is on to create a COVID-19 vaccine. That medical organisations are able to move so fast is wonderful and highlights the adaptability of innovation. However, along with the transmission we observed, it demonstrates that we weren't prepared. Not to mention that an effective vaccine is not guaranteed. Back in 2015, Bill Gates was talking about the possibility of the next pandemic. We clearly weren't ready five-years on.

Actually being ready doesn't necessarily mean having the drugs available. That's not sensible reflecting the development involved. It does however mean having robust international systems that can respond forcefully with established rules (e.g. immediate shutdowns, border controls) to a new disease. Hopefully, COVID-19 wakes us up to the future threats to global health and we work together proactively.


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