Managing Ebola: An Archaeology of Disease

July 1, 2015

Playing helpless witness to a growing epidemic with no cure takes us back in time. The Hippocratics called it the “art” of medicine. It does not take a psychiatrist, however, to see that this “artful” approach frequently fails in public health crises.

HISTORY OF PSYCHIATRY

[[{"type":"media","view_mode":"media_crop","fid":"38309","attributes":{"alt":"disaster psychiatry","class":"media-image media-image-right","height":"215","id":"media_crop_791150168623","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3797","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©Wallybird-Shutterstock","typeof":"foaf:Image","width":"263"}}]]A recent article in G7: Beyond 2015 quotes two leading Oxford medical researchers in the rearguard of several East African disease outbreaks. Dr Adrian Hill, director of the Jenner Institute on vaccine research, points out, “We know there will be more outbreaks. . . . Many viruses are lurking, and then there are going to be new viruses.” The views of his colleague, Professor Peter Horby, director of the Epidemic Diseases Research Group Oxford, are summed up: “The lessons from vaccines and therapeutics for Ebola . . . include our understanding of how outbreaks occur and spread . . . the effects of supportive clinical care and public health interventions, and understanding the impact of different human behavior and customs.”1

These two researchers would seemingly accelerate history. But playing helpless witness to growing and burgeoning epidemics with no cure is as common as warfare. Historical lessons are plentiful, especially with regard to “understanding the impact of different human behavior and customs.” With the vagueness of “madness,” the term “plague” has described catastrophic outbreaks of disease since the invention of writing, not far removed from the biblically inspired quarantine-from the Italian quaranta, forty, the number of days ships’ crew members were required to remain isolated in Venetian ports during the time of the black plague in Europe, the number of days Jesus fasted in the desert before beginning his ministry.

Indeed, an early physician’s greatest insight could be that disease was not curable, at least not through any physical machinations. Comfort, education, fortuitously placed and skillfully manipulated placebo (literally, in Latin, “I shall placate”) were the best that could be done in most cases, with perhaps, as the Greeks and later Arabs were wont to do, some empirical documentation as to the natural course of disease. This sounds a lot like psychiatry. The Hippocratics called it the “art” of medicine. It does not take a psychiatrist, however, to see that this “artful” approach frequently fails.

Witness the following early medical text, written not by a physician but by a disgraced general, a statesman-turned-journalist, as objective an eyewitness to disease as there ever has been. Here is Thucydides’ account of the unidentified, rapidly fatal plague that befell a besieged Athens in the second year of the first historical “30 years’ war.” This was the so-called Peloponnesian War (431-404 bc) for which Thucydides remains the definitive historian. This brutal civil war pitted the two lead-ing Greek city-states of the time-Athens and Sparta-against each other and hastened the end of the brief democratic experiment that had uniquely marked Athenian government for less than 100 years-the “Golden Age” of Greece.

The most famed statesman of the period, Pericles, succumbed to the fatal disease soon after his own glorified admonition, or funeral oration, to the citizenry to hold strong and steady through the crisis. Thucydides survived the disease.

(I offer my own interpretation here because Thucydides was, to borrow a recent reincarnation from Maureen Dowd, an “odd duck.” He has flummoxed translators since the second century bc with his idiosyncratic style, and he continues to defy definitive translation. The gist of the story is clear; the details are any-thing but. Like a good psychiatrist, in such cases, I prefer to lay my own eyes on the primary material.2 Or, as one of my weight-lifting patients once said to me, “Why travel light when you’re strong?”)

Let us skip over the more gruesome clinical manifestations of the disease and proceed to the psychosocial aspects in its wake.

The worst part of the illness was the profound depression that followed once one realized one had fallen ill. The immediate and unremitting despair into which those so afflicted fell, robbed them at once of any powers of resistance, and they became easy prey. Equally appalling was the swiftness with which the disease spread-constant, hideous spectacle of people dying like diseased sheep-and the commonest cause of morbidity was the very efforts of the well to minister to the sick. On the one hand, if one feared to venture out, one died of neglect; on the other, if one did venture forth, death was the sure consequence. This was especially so among those few left with honor. These did not spare themselves in attending their friends-even as hopeless family members wearied of the moans of the dying-and they quickly succumbed to the catastrophe.

Indeed, those who had chanced to recover from the illness were the most compassionate. They feared not for themselves any longer, as the disease did not attack the same man twice, at least not fatally. However, in the fleeting joy of the moment, too often these lucky ones entertained the vain belief that they would never fall ill again.

Aggravating this situation were the refugees from the countryside. As there were no safe places to receive them, they had to be lodged-during this, the hot season-in suffocating apartments where mortality raged. Bodies of the dying lay one upon the other like a scene out of hell, and the near-dead staggered up and down the streets, falling into the city fountains, desperate for water. The temples, too, were overrun with the sick and homeless, and laden with corpses as they died there. As the calamity progressed, hopeless and uncertain of their fate, no one cared a wit for anything, whether sacred or profane.

Burial rites were quickly discarded in favor of hasty immolations. Many had recourse to the most shameless of practices. Some threw bodies onto the waiting pyres of others and lit them; others threw bodies on top of pyres already burning.

Nor was this the only breach of law allowed by the plague. Many now committed outrageous acts in public. Witnessing rapid changes in fortune-the once prosperous suddenly dying and the opportunistic seizing their fortunes-many resolved to spend quickly, to make merry, regarding life and riches both as transient. Honor was not a pursuit among these. What did become quickly settled was that the pursuit of happiness was now considered “honorable.”

There was no longer any fear of god or man, and therefore no restraint. As for gods, it was considered all the same whether one worshipped or not as everyone alike lay perishing; as for man, no one expected to live long enough to be brought to trial for any offense. Each felt that a far more severe sentence had already been declared upon them all, hanging ever over their heads. One step ahead of fate, they deemed it only reasonable to enjoy life a little.3

One can almost see the mask of the red death hovering about the walls; can hear the fatalistic cry, “Ring out your dead!” Predating Camus by nearly 2500 years, The Walking Dead by even more, this plain account of disease raging within unwittingly quarantined walls is an existential slap in the face to any physician hawking wares as a healer. Compassion is the only measure of comfort here presented. It is prophetically, if morbidly, fitting that the plague detailed above remains unidentified. This description may well apply to the fight against leprosy, black plague, typhus and yellow fever, influenza, AIDS, and Ebola. In fact, this text emerged from the latter years of the first Golden Age of Medicine, the first Age of Reason, unfairly removed-by its designation as historical-from contemporaneous texts that repeatedly address the virtue of the physician, the higher calling of the healing arts.

And how might medical moralists such as Hippocrates and Galen have comported themselves in the midst of such misery? Perhaps, as most of us in psychiatry find ourselves trying to do on a daily basis, by orchestrating as best they could the fine line between suffering and recovery. The virtuous physician might hold the baton steady, and his performance could make all the difference. Thucydides sets the stage for medical heroes but acknowledges no one.

Medicine without cure is perhaps best conceptualized as a branch of philosophy, a fatalism, if not downright nihilism. The Hippocratics guarded against the desire to cure, recommending that physicians become expert on the natural course of disease to provide education and supportive care. They recognized that the body most often heals itself, and the physician should hinder that as little as possible. The supernatu-ral was removed from the equation, not out of a rational disbelief in the gods but from the accumulated evidence that the gods cared little for the recovery of sick humans.

Thucydides, an educated non-physician, provides one of the most objective accounts of the failure of medicine, of any era-not so much in his ghastly details of the course of disease, but in his unsparing description of the psychosocial consequences of disease. “De-moralizing” really is a powerful adjective, and in some ways, I suppose, in an environment where cure now becomes the exception rather than the rule, the early physician may have been better trained than his post-postmodern progeny.

This article was originally posted on June 3, 2015 and has since been updated.

Disclosures:

Dr Martin is currently an adult and pediatric consultation-liaison psychiatrist at Newton-Wellesley Hospital in Newton, Mass, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston. He has a Master’s degree in Near Eastern Languages and Cultures from UCLA, and was a high school Latin and Greek teacher before returning to medical school. He is the founder of the Yale Philosophy and Psychiatry Group, and has published several articles on historical, philological, and philosophical issues in psychiatry and medicine. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. The Authorized G7 Publication. Ebola: global health threats need a global research and development solution. G7: Beyond 2015. 2015:90-91.

2. Martin EB Jr. The virtuous physician: a new translation of a pseudo-Hippocratic text and its implications for the history of moral inquiry; or, the significance of an insignificant text. J Interdisciplin Hist Ideas. 2012;1(2):1-41.

3. Thucydides. The History of the Peloponnesian War. Crawley R, trans. 2009. http://www.gutenberg.org/files/7142/7142-h/7142-h.htm. Accessed June 15, 2015.