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The Black Death

All pandemic infectious diseases are rare and so medical educators must compete for time.

“It first betrayed itself by the emergence of certain tumours in the groin or the armpits, some of which grew as large as a common apple, others as an egg... merely by speech or association with the sick was the disease communicated to the healthy... any that touched the clothes of the sick... seemed to catch the disease... Many died daily or nightly in the public streets. Of many others, who died at home, the departure was hardly observed by their neighbours, until the stench of the bodies carried the news.”

This clinical scenario was written by Giovanni Boccaccio in Decameron (circa 1360). It is hard to better it as a description of the disease. The Black Death was caused by Yersinia pestis and it spread quickly throughout medieval Europe and the world. It was spread by many factors – not least poor hygiene and dreadful living conditions.

However, like all pandemic infections, ignorance also played a role in its rapid spread. Some people said the disease was caused by God’s anger at people’s sins. Others blamed foreigners or minorities. Some despaired and said that nothing could be done to prevent the disease – ignoring the fact that quarantine did work in some cities. These myths and counsels of despair served only to distract from the real cause of the pandemic and so acted as a barrier to its control.

Over six hundred years later, ignorance is still the greatest risk in the spread of pandemic infectious diseases. Simple measures can be taken that would have a great effect if they were universally adopted. The spread of Yersinia pestis can be prevented by early reporting and isolation of affected patients. But if patients or their relatives are scared to present to their doctor then urgent reporting and isolation will be impossible.

This is true of other infectious disease also. For example, patients with Ebola need to be isolated and reported to the relevant authorities. Relatives and healthcare workers who are caring for affected patients need to wear personal protective equipment. They also need to avoid direct contact with the body of someone who has died of the disease. These safe practices need to be followed meticulously but they can be a challenge in certain cultures, where relatives will want to touch their loved ones. In these scenarios, education will help but new cultural practices will need to be developed also. These might include smiling and nodding at people when you meet them as opposed to shaking hands. In Guinea, the highest ranking religious leader said there was nothing in the Koran “that says you must wash, kiss or hold your dead loved ones.” In saying this, he likely convinced many people and saved lives.

All pandemic infectious diseases are rare and so medical educators must compete for time in curricula and continuous professional development programmes to educate healthcare professionals on their diagnosis and management. Pandemic infectious diseases are all different and this makes it even more of a challenge.
However, there are themes that are common to all pandemic infectious diseases. The essentials of recognition, referral and reporting of such diseases are universal themes that apply to all. These three R’s might help with a wide range of diseases – from the ancient threats of Yersinia to the modern but equally deadly menace of Ebola. Education is our greatest weapon against them.

The purpose of this document is to educate and to inform. The content of this document does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care or treatment. The views expressed by contributors are those of the authors. BMJ does not endorse any views or recommendations expressed in this document. Readers should also be aware that professionals in the field may have different opinions. Users of this document hereby agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.

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