Social Distancing: A Brief Historic Perspective

Hans Barnard
It is obviously impossible to predict the future, but at times it may be advantageous to look at the past for guidance in the present. The current Covid-19 pandemic and the measures taken to mitigate its effects may be one of these times. Among the best recorded and studied epidemics in history are the 1665–1666 bubonic plague in England, which was an episode within the so-called Second Plague Pandemic, and the 1918–1919 influenza pandemic (the Spanish Flu).
Looking back at the latter in January 2006, the Defense Threat Reduction Agency (DTRA) published a report with the title A Historical Assessment of Nonpharmaceutical Disease Containment Strategies Employed by Selected U.S. Communities During the Second Wave of the 1918–1920 Influenza Pandemic.[1] In this report the authors focus on the lessons that might be learned from communities within the United States where the influenza pandemic resulted in a significantly lower numbers of deaths than could have been expected. These included, among others, the town of Gunnison (Colorado) and Princeton University (New Jersey).
To justify their research, the authors start with the prediction that “in the absence of adequate stocks of an effective vaccine and/or antiviral drugs, the United States may have to rely on non-pharmaceutical interventions (NPI) to contain the spread of an infectious disease outbreak until pharmacological means become available”.[2] This prediction became painfully true in early 2020 with the arrival of an infectious and potentially deadly novel corona virus.
After a discussion of a number of case studies, they write in their conclusion that “we should not be seduced into thinking we can easily translate these historical examples into contemporary situations”.[3] Next, however, they emphasize that “protective sequestration (the shielding of a defined and still healthy group of people from the risk of infection from outsiders), if enacted early enough in the pandemic, crafted so as to encourage the compliance of the population involved without draconian enforcement measures, and continued for the lengthy period of time during which the area is at risk, stands the best chance of protection against infection”.[4]
In the beginning of the twentieth century, Gunnison, Colorado, was a small silver mining town with about 1500 inhabitants and 5500 in the surrounding Gunnison County. Unlike most other western Colorado towns, Gunnison took an active interest in the influenza pandemic (Figure 1).[5] On October 31, 1918 local physician F. P. Hanson suggested strict social measures to be taken throughout the county. Residents were allowed to leave, but no one was allowed to enter unless first being in quarantine for 48 hours, which was later increased to five days. At times, travel within the county was also prohibited. Barricades with lanterns and warning signs were erected on the main roads, public gatherings prohibited, and all schools and public institutions closed. Violators did face the full force of the law, and several were jailed or fined. As a result, no one died of influenza in Gunnison County until March 1919.
Over time, the combination of fear, cabin fever, and restrictions on travel and social events started to wear down morale, and in mid-January 1919, schools were allowed to reopen. Attendance was on a voluntary basis, and nurses were hired to monitor the health of the students. All other restrictions were lifted on February 5, 1919. Mid-March 1919 a third wave of influenza reached Gunnison County, resulting in approximately 140 cases and the death of at least five young residents. The impact of the pandemic, however, was significantly less in Gunnison compared to its surrounding counties, where the measures where less strict and lifted earlier. “Gunnison was quick to enact NPI to reduce, if not outright prevent, the spread of influenza within county lines, and its public officials, medical officers, and residents should be commended posthumously for their boldness in action and cooperation in following these NPI”.[6] Award-winning author Thomas Mullen cites the event in Gunnison as a source of inspiration for his 2006 novel The Last Town on Earth.
Despite justified Cartesian doubt, the lesson from Gunnison seems clear: “in the event of another influenza pandemic, many specific subcommunities (e.g., military installations, college and university campuses, nursing homes) may wish to consider protective sequestration measures as potential means to prevent or delay the onset of epidemic influenza in their populations”.[7] The main issue faced by legislators and community leaders seems equally clear: “with children at home and with few social outlets, residents eventually grew impatient with the imposed isolation”.[8]
The first wave of any epidemic may be impossible to prevent as developments are unpredictable and swift. The effects of a second wave, however, can be mitigated by sensible, strict and long-lasting measures, as shown in the case of Gunnison and others. A third wave may occur if these measures are abandoned or ignored too early. The main and most difficult task of leadership in these circumstances may be clarification and motivation to keep morale high and the measures in place.
An older, but even more striking and touching example of the effects of quarantine on the course of a pandemic is provided by the small lead mining town of Eyam in Derbyshire, Great Britain.[9] Late in the year 1665 Alexander Hadfield, a tailor in Eyam, received a shipment of cloth or clothes from London, which at the time experienced a large outbreak of bubonic plague (the Great Plague of London). Within a week, Hadfield’s assistant George Viccars had opened the shipment and been attacked by the fleas hiding within it. He and several members of his household became ill and died of bubonic plague soon after. As the disease started to spread, William Mompesson and Thomas Stanley, the religious leaders of the community, took decisive action. In May 1666, they moved church services outdoors, ordered families to bury their own dead, and had boulders placed around the village which no one could pass to either leave or enter the village (Figure 2). These measures were only partly aimed at protecting the villagers, but mostly to prevent the spread of the disease into the surrounding area.
In the course of 14 months, at least 257 lives out of an estimated 700, were lost within the boundary stones. Within a week Elizabeth Hancock, who herself survived, buried six of her children and her husband. “This Eyam plague episode is celebrated as a remarkable act of collective self-sacrifice. The village community realized that the whole surrounding region was at risk from the epidemic and therefore decided to seal themselves off from the other surrounding villages. Thus their tragedy did not become a disaster for their neighbors”.[10]
Since 1866, the bicentenary of these events, the village remembers the dead every last Sunday in August (Plague Sunday). With the decline of lead mining and small-scale manufacturing of cloth and shoes in Eyam, tourism centered on the response of the village to the plague has become a major source of income.[11] Over the years, the events have inspired poems, books and even operas (such as Plague upon Eyam by John D. Drummond and Patrick Little and The Plague of Eyam by Ivor Hodgson).
The first lesson that can be learned from these case studies is that quarantine, protective sequestration, and social distancing, which are more or less different words for the same thing, are effective non-pharmaceutical interventions to mitigate the effects of a pandemic. The second lesson is that the main challenge, once the measures are in place, quickly becomes providing inspiration and motivation to maintain them as long as possible, certainly much longer than feels necessary. “Historically, the introduction of the cordon sanitaire has been considered remarkable, foremost as an act of altruism by the villagers under the direction of the rector William Mompesson and previous incumbent Thomas Stanley, and further because similar contemporary public health measures were unpopular and often disobeyed”.[12] The importance of charismatic figures such as doctor Hanson, the reverend Mompesson, and the reverend Stanley may be obvious to keep morale high and the measures in place. California governor Gavin Newsom, Los Angeles mayor Eric Garcetti, and UCLA chancellor Gene Block have done their best to provide similar leadership and inspiration. The academic community should do everything in its power to support them in these efforts and curb the second wave.
 
References Cited
Defense Threat Reduction Agency (2006), A Historical Assessment of Nonpharmaceutical Disease Containment Strategies Employed by Selected U.S. Communities During the Second Wave of the 1918–1920 Influenza Pandemic, Unclassified Final Report DTRA01-03-D-0017, Fort Belvoir (VA), Advanced Systems and Concepts Office.
Markel, Howard, Alexandra M. Stern, J. Alexander Navarro, Joseph R. Michalsen, Arnold S. Monto and Cleto DiGiovanni Jr (2006), Nonpharmaceutical Influenza Mitigation Strategies, US Communities, 1918–1920 Pandemic, Emerging Infectious Diseases 12(12), 1961–1964.
Massad, Eduardo, Francisco A. B. Coutinho, Marcello N. Burattini and Luiz F. Lopez (2004), The Eyam Plague Revisited: Did the Village Isolation Change Transmission from Fleas to Pulmonary? Medical Hypotheses 63, 911–915.
Race, Philip (1995), Some Further Consideration of the Plague in Eyam, 1665/6, Local Population Studies 54 (Spring 1995), 56–65.
Wallis, Patrick (2006), A Dreadful Heritage: Interpreting Epidemic Disease at Eyam, 1666–2000, History Workshop Journal 61, 31–56.
Whittles, Lilith K. and Xavier Didelot (2016), Epidemiological Analysis of the Eyam Plague Outbreak of 1665–1666, Proceedings of the Royal Society B283, 20160618, http://dx.doi.org/10.1098/rspb.2016.0618.

Endnotes

[1] DTRA 2006, summarized and published by Markel et al. 2006.

[2] DTRA 2006: 1.

[3] DTRA 2006: 134.

[4] DTRA 2006: 134.

[5] DTRA 2006: 56–73, summarized and published by Markel et al. 2006.

[6] DTRA 2006: 71.

[7] Markel et al. 2006: 1963.

[8] DTRA 2006: 73.

[9] Race 1995; Massad et al. 2004; Wallis 2006; Whittles and Didelot 2016.

[10] Massad et al. 2004: 915.

[11] Wallis 2006.

[12] Whittles and Didelot 2006: 2.

Captions to the Figures:
Figure 1: From the front page of the Gunnison News Champion, October 11, 1918. Image courtesy of the University of Michigan.
Figure 2: A boundary stone between Eyam and Stoney Middleton. The depressions in the stone were meant to be filled with vinegar and receive coins, which in this way were allowed to be passed across the boundary. Photograph taken by Bill Boaden (March 2007), CC BY-SA 2.0.