At the moment, Leicester has Britain’s worst Covid infection rate. One of the grim ironies of the city’s current plight is that once it blazed a trail for preventing the spread of infectious diseases. It was, admittedly, a long time ago – 1878 to be precise – but the story prompts the question: would the Victorians have handled this year’s pandemic better than we have done?
My journey down memory lane – amnesia lane might be more accurate, for this is a story of some important reforms that seem to have been forgotten – begins with a little family history. My great-grandfather, Sir David McVail, and his brother, John, were pioneers in public health at the end of the nineteenth century and beginning of the twentieth century. Both were based in Glasgow; between them they represented Scotland on the General Medical Council for more than 20 years. (When David retired, John succeeded him.) In particular, John became an international authority on how to stop the spread of smallpox, measles, scarlet fever, cholera and diphtheria.
I wondered what they would have made of the current pandemic. After a little digging, I came across a series of lectures that John gave in 1919, towards the end of his life, to the Royal College of Physicians. They are alarmingly relevant to what is happening today, above all to the controversies around contact-tracing.
He told how the “systematic surveillance of contacts” had begun to develop by the 1870s in a number of cities. In particular, Liverpool, Sheffield and a clutch of other cities in the Midlands and North managed to limit the local impact of a smallpox epidemic in the 1890s. One of them was Leicester. Indeed, John praised the city for the way it handled successive waves of smallpox. He cited an 1878 report in the British Medical Journal. Under the headline “Prevention of Smallpox in Leicester”. it told how Leicester’s medical officer of health “successfully adopted the plan of removing the inhabitants of the poorer houses in which a case of smallpox had occurred to a quarantine establishment in the hospital, and retaining them there for at least fourteen days”.
Here is how my great uncle went on to describe best practice:
“Surveillance is a routine duty of the most essential importance, and here the value of a trained and active public health staff becomes manifest. When the first case is discovered, and while it is being dealt with, the question of its origin is simultaneously investigated. The movements and doings of the individual before the development of the eruption, and for a day or two on either side of it, have to be rigidly investigated, and if the source of his infection is discovered it becomes a new centre of similar inquiries.
“Next the patient has to be questioned as to his movements during the period of potential infectivity. The household claims the first place. His place of employment, workshop or factory, has next to be thought of, also houses which he has visited – meetings, churches, reading-rooms, libraries, educational classes, public-houses and so forth. All these have this in common, that they give opportunity for indoor infection [which] is much more to be feared that outdoor.
“A list of contacts having been prepared in this way the necessary action is taken with regard to them. The date of contact should in each case be noted and the surveillance should have relation to the date.”
Note the high importance that John McVail gave to investigating “place of employment, workshop or factory” as a “routine duty”. Had his rules for contact tracing been followed this year, then one would hope that the scandal of what has happened in textile workshops in Leicester (and it is unlikely that the city is alone) would have been uncovered far sooner, with many lives saved and the need for a second lockdown prevented.
That is not the only disturbing lesson to be learned from John’s lecture. Where possible, for example with smallpox, he said that the best solution was to vaccinate and, if necessary, revaccinate the people contacted. But sometimes, vaccination might not be enough. In these cases, he approved a plan advanced back in 1868 by Sir James Simpson, at the heart of which was “seclusion or isolation which might be conducted either at home or in hospital”.
John went on to describe a mystery. Simpson’s plan for isolation was put before the Royal Commission on Vaccination in 1889. It provoked some controversy – and a shoddy sleight of hand. Most members of the Commission disliked Simpson’s plan. Not only did they refuse to support it; they went to some lengths to prevent the plan being mentioned at all in the final report. John describes what happened:
“The dissentient Commissioners in their Statement say that Simpson’s paper ‘will be found at page 40 of the fourth volume of our reports’. They believed so, but in fact the paper is not there. What at first glance appears to be the paper is there, but it is not the paper as published by Simpson. I pointed out with some fulness the misleading manner in which Simpson’s ‘proposal’ was placed before the Royal Commission.”
Fortunately, Simpson’s plan was gradually accepted and widely adopted, though not universally. But lives, and years, were lost in the meantime. But, of course, a strategy of isolation can work only if the people who need to be isolated are first identified.
The importance of institutional memory is well-known. So is the story of how contact tracing was curbed early in the current pandemic, and how warnings of the danger of this were ignored. A century after John McVail’s lectures, it seems that techniques for suppressing unwelcome ideas are remembered better than some of the hard-learned lessons of how to keep people well – not least in Leicester.
This article was first published by Prospect: https://www.prospectmagazine.co.uk/science-and-technology/how-would-victorians-have-handled-the-covid-19-pandemic-leicester