The plague under Marcus Aurelius and the decline and fall of the Roman Empire

Coping With Pandemics: A Historical Perspective About Society's Tools to Deal With Global Infectious Diseases

ABSTRACT

Throughout history, society has dealt with several devastating pandemics. Our objective is to analyze society's coping mechanisms to deal with pandemic-related stress in history congruent with the values of the time. For that purpose, we have carefully selected some of the most significant pandemics based on their impact and the available psychosocial literature. After a brief introduction, society's coping tools are reviewed and analyzed for the Antonine Plague, the second bubonic plague, the third cholera pandemic, the Spanish flu, the HIV pandemic, and the COVID-19 pandemic. Despite occurring at different times in history, parallels can be established in the study of society's psychological reactions among different pandemics. Magical thinking, political skepticism, fake accusations, and discrimination of minorities are recurrent reactions in society among different pandemics in history.

Preventive Measures against Pandemics from the Beginning of Civilization to Nowadays—How Everything Has Remained the Same over the Millennia

As of 27 March 2022, the β-coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected more than 487 million individuals worldwide, causing more than 6.14 million deaths. SARS-CoV-2 spreads through close contact, causing the coronavirus disease 2019 (COVID-19); thus, emergency lockdowns have been implemented worldwide to avoid its spread. COVID-19 is not the first infectious disease that humankind has had to face during its history. Indeed, humans have recurrently been threatened by several emerging pathogens that killed a substantial fraction of the population. Historical sources document that as early as between the 10th and the 6th centuries BCE, the authorities prescribed physical–social isolation, physical distancing, and quarantine of the infected subjects until the end of the disease, measures that strongly resemble containment measures taken nowadays. In this review, we show a historical and literary overview of different epidemic diseases and how the recommendations in the pre-vaccine era were, and still are, effective in containing the contagion.

All roads lead to Rome: Aspects of public health in ancient Rome

Modern western civilization can be traced back to the Roman antiquity in terms of policy, legislation, art, and culture. The development of ancient Rome from a kingdom in Latio to a democracy and finally a thriving empire has paved the way for medicine and public health. As a kingdom, Rome has established laws for maternal health and abortion. Later on, as a democracy, Rome payed special attention to sanitation and infections control building aqueducts and public baths. During the imperial period, apart from the aforementioned, Roman administration improved public health measures with regard to pandemics. The correlation of infectious outbreaks with animals, are considered as one of the first noticed of zoonotic diseases in the field of public health. The term public health itself (medici publici) can be traced back to doctors appointed with public health and disease control duties in Ancient Rome.

Pandemics Throughout the History

As we move amidst the coronavirus disease 2019 (COVID-19) pandemic, we have witnessed tremendous distress, death, and turmoil of everyday life for more than one year now. However, they are not modern phenomena; deadly pandemics have happened throughout recorded history. Pandemics such as the plague, Spanish Flu, HIV, and Ebola caused deaths, destruction of political regimes, as well as financial and psychosocial burdens. However, they sometimes resulted in scientific discoveries. Understanding the mechanism of the emergence of these pandemics is crucial to control any spreading pandemic and prevent the emergence of a potential new one. Public health agencies need to work on improving the countries' pandemic preparedness to prevent any future pandemics. The review article aims to shed light on some of the deadliest pandemics throughout history, information of critical importance for clinicians and researchers.

Radiological, epidemiological and clinical patterns of pulmonary viral infections

Respiratory viruses are the most common causes of acute respiratory infections. However, identification of the underlying viral pathogen may not always be easy. Clinical presentations of respiratory viral infections usually overlap and may mimic those of diseases caused by bacteria. However, certain imaging morphologic patterns may suggest a particular viral pathogen as the cause of the infection. Although definitive diagnosis cannot be made on the basis of clinical or imaging features alone, the use of a combination of clinical and radiographic findings can substantially improve the accuracy of diagnosis. The purpose of this review is to present the clinical, epidemiological and radiological patterns of lower respiratory tract viral pathogens providing a comprehensive approach for their diagnosis and identification in hospitals and community outbreaks.

Brief History of Pandemics (Pandemics Throughout History)

Intermittent outbreaks of infectious diseases have had profound and lasting effects on societies throughout history. Those events have powerfully shaped the economic, political, and social aspects of human civilization, with their effects often lasting for centuries. Epidemic outbreaks have defined some of the basic tenets of modern medicine, pushing the scientific community to develop principles of epidemiology, prevention, immunization, and antimicrobial treatments. This chapter outlines some of the most notable outbreaks that took place in human history and are relevant for a better understanding of the rest of the material. Starting with religious texts, which heavily reference plagues, this chapter establishes the fundamentals for our understanding of the scope, social, medical, and psychological impact that some pandemics effected on civilization, including the Black Death (a plague outbreak from the fourteenth century), the Spanish Flu of 1918, and the more recent outbreaks in the twenty-first century, including SARS, Ebola, and Zika.

Bayesian reconstruction of the evolutionary history and cross-species transition of variola virus and orthopoxviruses

Variola virus (VARV), the causative agent of smallpox, is an exclusively human virus belonging to the genus Orthopoxvirus, which includes many other viral species covering a wide range of mammal hosts, such as vaccinia, cowpox, camelpox, taterapox, ectromelia, and monkeypox virus. The tempo and mode of evolution of Orthopoxviruses were reconstructed using a Bayesian phylodynamic framework by analysing 80 hemagglutinin sequences retrieved from public databases. Bayesian phylogeography was used to estimate their putative ancestral hosts. In order to estimate the substitution rate, the tree including all of the available Orthopoxviruses was calibrated using historical references dating the South American variola minor clade (alastrim) to between the XVI and XIX century. The mean substitution rate determined by the analysis was 6.5 × 10^-6 substitutions/site/year. Based on this evolutionary estimate, the time of the most recent common ancestor of the genus Orthopoxvirus was placed at about 10 000 years before the present. Cowpox virus was the species closest to the root of the phylogenetic tree. The root of VARV circulating in the XX century was estimated to be about 700 years ago, corresponding to about 1300 AD. The divergence between West African and South American VARV went back about 500 years ago (falling approximately in the XVI century). A rodent species is the most probable ancestral host from which the ancestors of all the known Orthopoxviruses were transmitted to the other mammal host species, and each of these species represented a dead-end for each new poxvirus species, without any further inter-specific spread.

A 2-year review of the general internal medicine admissions to the British Role 3 Hospital in Camp Bastion, Afghanistan

BACKGROUND

Detailed knowledge of the likely volume and nature of the diseases presenting to deployed secondary care facilities aids operational planning. Now the British operation in Afghanistan has ended and a record of the experience is useful to preserve the lessons learned.

METHODS

Over a 2-year period from April 2011, prospective demographic and clinical data were collected on consecutive general internal medicine admissions to the Role 3 Hospital in Camp Bastion, Afghanistan. Up to four different symptoms and diagnoses were coded using the WHO International Classification of Disease, V.10 for each patient.

RESULTS

A total of 1368 medical patients were admitted. Of 1131 military admissions, 612 were from the UK (54.1%) and the remainder from 13 allied countries; 237 civilians came from 23 countries. Civilians were older than the military patients (p<0.001) but included five children. The 20 most frequent presenting symptoms were identified and there were 1626 diagnoses made. The 10 most frequent diagnoses were infectious gastroenteritis (12.6%), heat illness (4.3%), pneumonia (3.6%), epilepsy (2.6%), cellulitis (2.7%), migraine (1.8%), peptic ulcer disease (1.2%), myocardial infarction (1.2%), venous thromboembolism (1.2%) and pericarditis (0.7%). In 252 cases (18.4%) a firm diagnosis was not reached and a symptom was recorded. The five most frequent of these were undifferentiated febrile illnesses (4.6%), syncope (3.7%), chest pain (2.8%), headache (0.8%) and palpitations (0.7%). The mean hospital length of stay was 1.59 days and 72.2% of UK military patients were 'returned to unit'. Three civilian patients died in hospital or following aeromedical evacuation and there were no deaths of any military patients.

DISCUSSION

This study demonstrates the wide variety of presentations seen by physicians at an established military field hospital. This information informs the core syllabus of military physician training and will help facilitate planning for future medical support to similar military operations.

TRIAL REGISTRATION NUMBER

RCDM/Res/Audit/1036/12/0305.

Emerging and re-emerging infectious diseases: challenges and opportunities for militaries

The communal nature of living and training environments, alongside suboptimal hygiene and stressors in the field, place military personnel at higher risk of contracting emerging infectious diseases. Some of these diseases spread quickly within ranks resulting in large outbreaks, and personnel deployed are also often immunologically naïve to otherwise uncommonly-encountered pathogens. Furthermore, the chance of weaponised biological agents being used in conventional warfare or otherwise remains a very real, albeit often veiled, threat. However, such challenges also provide opportunities for the advancement of preventive and therapeutic military medicine, some of which have been later adopted in civilian settings. Some of these include improved surveillance, new vaccines and drugs, better public health interventions and inter-agency co-operations. The legacy of successes in dealing with infectious diseases is a reminder of the importance in sustaining efforts aimed at ensuring a safer environment for both military and the community at large.

[Marcus Aurelius Antonius (121-180AD), philosopher and Roman emperor, and Galen's plague]

The study of the aetiologies of diseases in Ancient Times is usually a speculative intellectual exercise. When some authors attribute a specific aetiology to an old disease, there is a great risk of committing a methodological error, known as presentism by the modern historiography. The authority of the investigator, more than the weight of the scientific truth, is usually the reason why the diagnosis has remained over the years. The great epidemic of the years 164-165AD and afterwards, could have been smallpox (haemorrhagic form). Claude Galen, the famous doctor, described the symptoms in several books of his great Opera Omnia. For this reason, it is currently known among the scholars as Galen's plague. The epidemic was described for the first time in Seleucia (Mesopotamia). Until now, the actual geographic origin is unknown. We propose here that the beginning might be the kingdom of the old Han dynasty (now the Chinese Popular Republic). The epidemic swept the Roman Empire, from the east to the west, and from the southern to the northern borders. An immediate consequence of the infection was a high morbidity and mortality. In this sense, Galen's epidemic was one of the many factors that caused the fall and destruction of the Roman Empire. On the other hand, there is a general agreement among historians, biographers and researchers that the philosopher emperor Marcus Aurelius Antoninus (121-180AD was affected by the infection in the epidemic wave of 164-165AD. The death of Marcus Aurelius occurred on March 17 in the year 180AD, in Vindobonne, or perhaps Sirminium (near to Vienna). Many authors propose that the cause of the emperor's death was the same epidemic. We consider that it is not possible to demonstrate any of those speculative diagnoses. Finally, the epidemic of 189-190AD, that we have named of Commodus, was probably a different disease to the Galen's plague. There were several kinds of animals affected (anthropozoonoses). In this sense, this infection resembles more the previous Athens plague (430BC) or the epidemic of Justinian (552AD) than that of Galen's.

Great Plagues of the Past and Remaining Questions

Due to the difficulty of obtaining tissue samples from victims of the ancient plagues, it is not always possible to utilise palaeomicrobiology techniques to determine the etiology of ancient infection. Therefore, it is often necessary to utilise other means to arrive at a likely diagnosis. The most helpful of these is the literary description of the disease. While this is often the best evidence available, working with such documents can prove difficult. Three great plagues of the ancient world, the Plague of Athens, the Antonine Plague, and the Justiniac Plague are described in either Latin or ancient Greek. The difficulties encountered when translating any ancient foreign language are compounded by the fact that so many words in these languages have a variety of meanings. This chapter reviews the three great plagues of antiquity from a clinical perspective.