It is 2:15 a.m. during the spring of 2014; ominous, dark, and quiet as death is about to take its toll in Foya, Liberia. Joseph Gbembo runs to the village pastor’s home, pushing a wheelbarrow through dirt roads as he is informed that his brother Prince has been vomiting all night; he has contracted Ebola, and Joseph is scared. The Ebola virus has made its way to his small town in Africa, where it’s begun to prey on its victims at alarmingly high rates. Joseph arrives at the house and knows that he cannot touch his brother, as the infection will spread. He covers his hands and lays his dying brother in the dirty barrow. Adrenaline pulses as Joseph rushes him to the hospital, but a family member stops him in his tracks, forcing him to take Prince home. He passed away 15 hours later. Joseph describes this moment saying, “At the hour of 7:35 p.m. he died right in the room here…He was so good to me as a brother…I miss him so much…I always feel pain in my heart.” After Prince passed, seventeen other family members died from the ravenous Ebola virus: his mother, four aunts, four brothers, sister, three nephews, two sisters-in-law, a brother-in-law, and uncle. He is now the “father” of 16 children that his family members left behind.
Joseph Gbembo is not the only person to experience immense pain due to infectious diseases that take the world by storm. Epidemics have infected global populations since the beginning of time, with the most prominent being the Black Death, which hit major Italian port cities in 1346. Other major epidemics include Smallpox and AIDS. Although these are different types of epidemics, they have one thing in common: these infectious diseases are rapidly spread to a given population through the direct or indirect transmission of a pathogen to a host.
Pathogens are everywhere in our environment, and as humans, we are many times the target or host of them. Through our social interactions with one another, we have the ability to spread these infectious particles at rapid speeds. Once these pathogens infect a population that is not immune to them, sickness and death will occur, in some cases wiping out whole populations; this is an epidemic. In this paper I will discuss how migration, war, and trade have correlated to the transmission of disease in modern global history, and how these three types of social interactions led to the spread of the Bubonic Plague, Smallpox, and HIV/AIDS; diseases that will forever be recognized as causing some of the deadliest epidemics in the world. Additionally, I will explain how resource availability and access to treatment can alter the rate and severity of diseases that cause these epidemics.
In 1346 a great number of Tartars from Asia succumbed to an illness that caused unforeseen death. Towns fell apart as populations were decimated by disease, but this did not hinder the Tartars from fighting. They besieged a settlement north of Constantinople called Tana, where Italian merchants tended to sell and trade their goods. Out of fear of the Muslim armies, the merchants fled Tana and sailed to the Genoese trading port, Caffa. The Tartars followed these merchants in droves to besiege their new settlement (Plague 4), but unfortunately they unknowingly brought with them a zoonotic bacterium that caused what might be known as the worst epidemic in human history, the Bubonic Plague (Plague 3).
This microscopic bacterium is known today as Yersinia Pestis, which enters the human lymphatic system through the bite of an infected flea. The flea contracts the bacterium from rodents. Once the bacterium enters the lymphatic system, it travels to the lymph nodes, where it produces symptoms, such as high fever, body chills, aches, weakness, vomiting, and extreme fatigue. As the infection spreads, the lymph nodes become inflamed and painful, and as it continues advancing, the lymph nodes turn into large open sores. People die because of these excruciatingly painful sores and septicemia. The infection is fatal within one week with no treatment (Plague 5). Sadly, due to lack of knowledge and medical advancements, the Bubonic Plague caused widespread death across all of Europe during the 14th century, and the Tartar invasion of Caffa was just the beginning of this global crisis that hit Europe.
The Muslim Tartars methodically invaded the city of Caffa on all sides, trapping the Christian settlement for three years. But this later backfired as the whole Tartar army became affected by the Plague, which proved to be an active agent in biological warfare; thousands of soldiers were killed per day, with open sores creating a rancid odor that encompassed the post. Gabriele de’ Mussi, a clerk from Piacenza, Italy, wrote a vivid narrative about the Siege of Caffa (Plague 6). In this he detailed the horror of the disease and the Tartars’ response. He explained that the Tartars were so overtook by the devastation that the Plague had on its armies that they eventually withdrew from their battle against the Christians on Caffa. De’ Mussi wrote, “They ordered corpses to be placed in catapults and lobbed into the city in the hope that the intolerable stench would kill everyone inside…the Christians could not hide or flee or escape from them, although they dumped as many of the bodies as they could in the sea.” The dead bodies contaminated air and water supplies, and the stench consumed all. But no one left alive understood that once infected, one could carry the disease to anyone else to whom he or she came into contact (Plague 4).
Through trade, the Bubonic Plague spread across the rest of Europe over the next couple of centuries, beginning in the Sicilian port of Messina, Italy. The survivors from Caffa sailed westwards along the Mediterranean cost on their Genoese trading ships in the hope of trade and commerce, helping them build a new life. Some ships stopped in Marseilles, France and others in Spain; all of them carrying infectious rats aboard. Within two years, all of Europe became prone to the Plague with many living in rat-infested cities where disease flourished (Plague 2).
During this period in history, medicine was nothing but medieval. Medical knowledge was little to none, especially in the sector involving infectious disease. No one understood the origin of disease or the best preventative means to combat it. Nevertheless, they did their best with the knowledge they had. In 1568, Thomas Hobson, a skilled businessman living in Cambridge, England, tried to prevent further Plague outbreaks by paying for a aqueduct that ran through the town. This duct allowed fresh water to flow through the streets, therefore ridding the town of disease (Plague 1). Due to the fact that the epidemic occurred before the Enlightenment period, many believed that the plague was sent from God as a punishment to all for their ungodly sins, such as fornication; plague symptoms were analogous to those of STIs. Other theories included the alignment of Saturn with Jupiter and Mars in November and October of 1664 and an “earthly miasma” due to vapors from the pungent filth and overcrowding of cities (Plague 1). Renaissance Galenists even went as far to believe that “seeds” were the cause of plague. These were thought to create a bodily imbalance of four substances that made up the human body: blood, black and yellow bile, phlegm (Plague 2). All of these theories proved wrong.
But after five-and-a-half centuries of extreme desolation, Dr. Alexandre Yersin uncovered the true cause of plague in 1894. Bacteriology became a newfound science, and he discovered that infected rats were the host for the bacillus-shaped bacterium, Yersinia Pestis. In 1898, French physician P. Simond had a clinical discovery. In fact, he found that plague spread to humans through an infected fleabite. But there was still no definitive cure. The College of Physicians believed that in order to prevent the plague, one needed to start with prayer. It also suggested chewing tobacco, trying new diets, and hanging pomanders made of herbs around one’s neck (Plague 1). These were obviously not effective treatment options, as antibiotics are necessary to kill bacterial infections. If there had been an accurate understanding on the cause of Bubonic Plague and available resources to treat and educate the affected populations, the rate and severity of the epidemic could have been lessened.
Nevertheless, as the medical sphere has made advancements in the modern globe, we have been able to combat further Bubonic Plague outbreaks, in the hope of eradicating the disease once and for all. Luckily, today the plague is an easily preventable and curable disease when caught early. For example, when the plague hit Madagascar, Africa in August 2017, the World Health Organization (WHO) sent health professionals, funds, and adequate supplies to the island to stop the plague’s rapid spread. The organization worked alongside the Government of Madagascar and surrounding countries to assess the current spread of the plague. From August to October 2017, there were a reported 1800 confirmed plague cases in Madagascar, and only 127 deaths. This is extremely low in comparison to the death toll during the mid-14th century. WHO has worked on establishing preventative measures through the creation of plague preparedness checklists, and emergency kits that include protective equipment and antibiotics (Plague 7). As of October 6, 2017, WHO has even dispatched roughly 1.2 million doses of antibiotics and $1.5 million in emergency funding to Madagascar (Plague 8). Today we have the proper resources and understanding of disease to make the Bubonic Plague confined and curable, unlike the former outbreak. If the resources we have available today were available to the Tartars in 1346, history may have had a different outcome, and many lives may have been saved.
Nearly a century after the spread of the Bubonic Plague in Europe, the Europeans brought with them a new weapon of disease to the New World. This disease proved to be the strongest factor in the European success of colonization of the Americas. But it also marginally disturbed the success of the Trans-Atlantic Slave Trade. In 1518, a group of European settlers migrated to the Caribbean islands, but they were not the only ones to migrate; so did the Smallpox virus (Smallpox 1). Smallpox is an acute contagious disease (Smallpox 7). It spreads from person to person through virus-infected mucous droplets coming from the respiratory system of an ill person by coughing, sneezing, or simply talking (Smallpox 3). Symptoms include high fever and a characteristic rash that results in permanent scarring (Smallpox 8) due to fluid and pus-filled spots on the face, arms, and legs (Smallpox 4). In advanced cases, blindness may occur (Smallpox 8). The disease has since been eradicated, but it is still considered another one of the deadliest epidemics in global history.
When the Europeans arrived to North American settlements, they also brought with them multiple communicable diseases, with the most prominent being Smallpox. The different Native American populations that came into contact with these European colonists had no prior exposure to these diseases; therefore their immune systems had no active defenses against them. The same goes for the African slaves forced against their will onto ships steaming with Smallpox virus (Smallpox 2).
With an end goal of colonization, the European colonizers needed to expel the native populations from their proper lands. The original thought was to forcibly remove them through the use of weapons like firearms, but little did they know, they were the host reservoir for Smallpox, a disease that proved to be a more effective and effortless way of achieving their goal. These European carriers did not realize that they were indeed carrying the virus that decimated not only the tribes of Amerindians, including the Taino, Abenaki, and Powhatan, but roughly 90% of the North American population by the end of the 16th century (Smallpox 2).
In 1520, a Smallpox epidemic occurred in Hispaniola. This specific outbreak wiped out two-thirds of the native Taino population. The Taino Indians living on this island were subject to harsh slave labor on the plantations and lived in cramped quarters, leading to greater susceptibility to infection. Moreover, the Taino Indians of Hispaniola traded with Tainos living on neighboring Caribbean islands. This drove the expansion of Smallpox to other areas of the world. As for the Powhatan tribes, they lived in Jamestown, Virginia, in extremely close proximity to the new settlers. Unfortunately, this meant that droves of Powhatan Indians surrendered victim to this infectious disease (Smallpox 2). This Smallpox virus unknowingly aided the Europeans in reaching their end goal of colonization of native lands.
On the contrary, the infectious Smallpox virus did appear to have negative effects on trade and commerce, as it annihilated African slaves on their heinous travels crossing over the Atlantic Ocean to the New World. Because the majority of Native Americans died off, the newly settled Americans needed to find a new form of slave labor to maintain their plantations; without the plantations, global trade stops and revenue significantly decreases. Other countries, such as Spain, Portugal, and the Netherlands had already become part of the African slave trade and proved successful. The Americans followed suit (Smallpox 1).
Ship after ship sailed to the coast of West Africa to seize their “negroes” from the barracoons; densely-packed prisons of enslaved Africans collected from both African tribal chiefs and traders. These barracoons became holding cells for disease. The ships carrying the slaves were congested and living conditions were repulsive. No longer were these African men and women treated like humans but animals. Smallpox flourished aboard the ships that consistently traveled back and forth from Africa to America. Without proper sanitation of these ships, infection was undeniable (Smallpox 1). The slave traders abstained from allowing ill slaves onboard, but seeing Smallpox has a long incubation period, it was difficult to regulate (Smallpox 3). Many of the slaves were quarantined on the ships once they landed on American soil. But indubitably, money was of upmost importance to the slave owners. Owners depended on slave labor to make a profit off of their plantations. They did not have time to wait for the newest batch of slaves to come out of quarantine, so they would risk exposure to the Smallpox infection rather than lose a pretty penny from a loss of trade (Smallpox 1). To say the least, Smallpox continued to flourish.
Smallpox expanded to countries around the world for centuries more until it’s eradication in December 1979 (Smallpox 4). It is considered the first and only eradicated infectious disease on Earth (Smallpox 10). But that is not to say that it was an easy road to get to eradication. For centuries, no one was sure of the cause or treatment of Smallpox. In medieval history, herbal remedies were used, but around the 17th century, inoculation was introduced to the world of medicine. In order to inoculate the Smallpox virus, a lancet was used to take a fresh sample of pus from an infected person and introduce the virus into the subcutaneous tissues of a nonimmune person. This practice proved successful, and physicians on a substantially greater basis practiced inoculation, which later became known as variolation. Finally in 1796, British surgeon, Edward Jenner made a revolution in his study of the effects of cowpox; he would forever change the world. He often heard stories that dairymaids that had cowpox were naturally immune to smallpox. He researched and concluded that cowpox protected against smallpox and could be used as a means of prevention against the smallpox virus. In May of 1796, Jenner took pus from a fresh cowpox wound on dairymaid, Sarah Nelms’ hand. He inoculated an 8-year-old boy with the sample. Two months later, Jenner inoculated the same boy with pus from a smallpox sore and nothing happened (Smallpox 50). His experiment worked, and a vaccination was complete. Due to the new vaccination, populations all over the world began protecting themselves against the deadly disease. If this vaccination and knowledge had been available to the Native Americans and African slaves in the 16th century, the overwhelming majority of deaths and illness could have been prevented.
However, in 1967, WHO launched an Intensified Smallpox Eradication Program. Smallpox was still devastating countries in Africa, Asia, and Latin America. This program would help with the eradication of smallpox in these lesser-developed areas of the world. It was composed of two components, one being mass vaccination, and the other being preventative care through education. In 1977, the last outbreak of naturally occurring smallpox was eradicated from Somalia. This was remarkable, although today, we are seeing the reemergence of smallpox in the news due to bioterrorist threats from other countries (Smallpox 10). As we progress to the future, hopefully we will not have to revisit the past.
Smallpox has been on this Earth since the beginning of human history. HIV, however, is a discovery of the 20th century. In the early 1980’s, five young and gay men living in Los Angeles, California were diagnosed with Pneumocystis carinii pneumonia, or PCP; an extremely uncommon disease. Of the five, two of the men died within short periods from one another. The CDC published a report on June 5, 1981 about these findings, but little did researchers know this was about to be one of the biggest modern day epidemics in global history.
More and more reports of rare cancers and illnesses, like Kaposi’s Sarcoma, were diagnosed in gay men in New York and California. One month after the publication of the initial CDC report, 41 additional gay men living in the aforementioned states were diagnosed with Kaposi’s sarcoma. By December, 121 men died from immunocompromised systems (AIDS 1). Research was underway to uncover the cause of this strange immunodeficiency. In 1982, health officials coined the term “acquired immunodeficiency syndrome,” or AIDS, to characterize previously healthy people who suddenly fell ill to rare forms of cancer and infections. Finally in 1983, scientists identified the silent killer: HIV.
HIV is a retrovirus that enters the human body through direct contact with other HIV-infected body fluids. Such fluids include semen, vaginal secretions, breast milk, and blood (AIDS 2). Once in the body, the HIV attaches and fuses to the white blood cells, T-helper cells, taking over the cells and its DNA. The virus replicates inside of the hostage T-helper cell and then releases more HIV into the bloodstream (AIDS 3). The immune system shuts down as CD4 cells are destroyed. Once one’s CD4 cell count hits 200 or less, one develops AIDS. Without treatment, AIDS is deadly (AIDS 7).
Due to technological advances unheard of during the Bubonic Plague and smallpox epidemics, scientists were able to determine the origin of the modern day disease in little time. They determined that HIV stems from a subtype of chimpanzee living in Western Africa (AIDS 4) and concluded that the HIV virus first entered into the bloodstream of African hunters through bushmeat trade. When these African men hunted and killed chimpanzees, they were in direct contact with SIV positive blood; blood contaminated with Simian immunodeficiency virus (SIV), the primate version of HIV. If any cuts or scratches were exposed to the infected blood of the chimpanzee, infection occurred shutting down the immune systems of these hunters (AIDS 5).
Researchers believe that Africans have been exposed to SIVs for centuries, but the real global spread occurred after colonization of the continent. Colonization brought with it new technologies and better infrastructure, such as new modes of transportation. Formerly isolated African villages and towns were much more connected than ever before, allowing the virus to spread from one village to another due to increased contact and multiple sexual partners. Even with the improved infrastructure, the African healthcare system still remained very poor. With little resources and inadequate funds, hospitals resorted to reusing needles (AIDS 5), unaware that they were spreading HIV in the process. Due to the slow progression of the virus, it may stay dormant for years. The infection was unheard of, and no one was aware that they were infected, so the virus kept spreading (AIDS 5). Through interconnected trade and travel, HIV was spread to other parts of the world, making it the biggest ongoing global epidemic today.
After the initial identification of AIDS in 1983, there was a steady rise in the number of HIV and AIDS diagnoses throughout the world. The virus further spread to Europe and Asia, and it soon developed in heterosexual females and children, significantly through the natural birth process. This was a mind-blowing phenomenon as HIV and AIDS were believed to only affect homosexual men. Two years later, in December 1985, the virus, with more than 20,000-reported cases, affected every region of the world. One year later, that number nearly doubled with 38,401-reported cases of AIDS spanning 85 countries. America had the highest prevalence, whereas Africa had one of the lowest (AIDS 7).
The tables have turned since the mid-1980s, with two-thirds of the HIV/AIDS-infected population living in sub-Saharan Africa today (AIDS 8). For example, South Africa currently has 7.1 million people living with HIV versus 1.2 million in the United States (AIDS 9). This is a large disparity considering the United States has a population of 331 million, and South Africa only has 55.9 million people. The large gap between the two countries has to do largely with resource availability, access to healthcare, and cultural and social progress. In Africa, many topics are considered taboo. Homosexuality is not tolerated, as it is in the United States and other European countries. Many homosexual males living in South Africa and other neighboring regions, do not discuss their sexuality to their healthcare providers due to stigma and discrimination. This provides a disservice to these men because they are not receiving proper treatment for HIV prevention and management. Lack of male circumcision also poses a problem, as circumcision can stop the spread of HIV by nearly 60%. Prostitutes face the same dilemmas because of their work. If a woman is found carrying a condom, she could be jailed. It is considered a criminal offense. Furthermore, prostitutes are not receiving any HIV prevention education because of police brutality. A female prostitute in Cape Town exclaimed, “The police officer raped me, then the second one, after that the third one did it again. I was crying after the three left without saying anything” (AIDS 9).
The effects of HIV/AIDS heavily impacts orphans and vulnerable children all over Africa, especially young girls. There are more than 2.3 million children living in South Africa that are orphans due to the effects of AIDS on their parents. They are also the most vulnerable because they are often forced into sex labor (AIDS 9). Although there is an increase in worldwide funding and educational programs, such as ZAZI, Brothers For Life, DREAMS, and PEPFAR, a private source that lives in KwaZulu Natal, an area with one of the largest HIV prevalences in the world, explains that there is little visibility with prevention, positive living initiatives, or stigma awareness. The source explained that multiple sexual partners and “blessers,” or “sugar daddies,” are the biggest source driving the HIV/AIDS epidemic in not only South Africa, but also Africa as a whole. Young women will have sex with older men to pay for school or household necessities and then have sex with partners their own age.
HIV education has dropped from 160% in 2013 to 20% in 2014 (AIDS 9). In 2007, a study was done on HIV/AIDS education programs in Uganda. Education was not helpful, as textbooks were outdated, teachers were not trained, and safe-sex practices, were not discussed (AIDS 10). The same problem is still occurring today in other regions of sub-Saharan Africa (AIDS 9). So although there have been many prevention efforts coming from non-governmental organizations (NGOs) and worldwide organizations, like WHO and UNAIDS, the progress is still lagging, which leads to the high HIV/AIDS prevalence seen today.
On the contrary, the United States is the largest funder of the HIV epidemic in the world. In 2010, President Obama announced his HIV/AIDS strategy that fought to reduce new HIV infections, increase healthcare access to all, and create a national plan to combat the disease (AIDS 9). The U.S. also has also had a greater access to the five classes of antiretroviral drugs and HIV education in schools (AIDS 11). Africa has never had a strong or renowned healthcare system. As other areas of the world, such as the United States and Europe were actively fighting against the further spread of the destructive virus, Africa did not have the necessary funds needed to purchase these expensive drugs or resources to educate their vulnerable population until 2001, 11 years after the FDA approval of the first antiretroviral drug in the U.S. (AIDS 7), when the United Nations created a “global fund” to support countries with high HIV populations. Major pharmaceutical manufacturers lowered their prices on these drugs, and resources were being sent to different countries in Africa to treat the growing number of HIV/AIDS patients (AIDS 7).