Danse Macabre, Michael Wolgemut, 1493. Wikimedia Commons/Public domain. Some rights reserved.From time to time, human society been subjected to infectious diseases, sweeping across vast swathes of territory and killing thousands, even millions, on their way. Their spread is largely a consequence of human actions, of trade, warfare, and the spread of communications. These actions of course have been involuntary, and their effects indirect, but often enough they have been interpreted as something quite different, namely the products of deliberate conspiracies designed to eliminate the unwanted.

The catastrophe of the Black Death, which killed up to half the entire population of Europe in 1348-49, was seen by townspeople in some of the most affected areas, notably in the Rhineland, as the result of Jews, a hated and feared religious minority, poisoning people’s drinking wells, a belief that led to widespread massacres and pogroms of Jews across the region.

In the nineteenth century, as a deadly wave of cholera infection swept across Europe, brought to it for the first time from the east, a series of riots and disturbances vented popular anger on the medical profession, accused in Britain, for example, of deliberately killing people to sell their bodies to the anatomy schools – as the murderers Burke and Hare had recently done in Edinburgh. In the century’s last cholera epidemic, in 1892, similar riots broke out in Astrakhan and Saratov, on the Volga, expressing the mistrust and suspicion in which ordinary people held government medical officials.

These riots were a response to the heavy policing measures by which the state attempted to combat the disease: forcible quarantining of houses, isolation of victims, mass burials, compulsory hospitalization. Yet at the same time the spread of the 1892 epidemic to Hamburg, the only city in western Europe to be seriously afflicted by the disease, did not prompt any outburst of popular rage: the educative influence on the already literate and well-informed working class in the city of the Social Democratic movement, with its belief in the virtues of modern science, ensured cooperation between the masses and the medical profession in dealing with the outbreak.

Even more instructive was the contrast between the two epidemics to hit Naples, in 1884 and 1910. In 1884, the Italian state mobilized military force to repulse the migrants and outsiders whom it accused of bringing the disease to the city. Quarantines were imposed by the military, and victims were forcibly taken off to the hospitals, where they were subjected to painful treatments including the administration of electric shocks and the purging of the intestines with strychnine – not surprisingly, death rates in the poorly organized and badly equipped hospitals were very high. The municipal authorities were notoriously corrupt and in league with local crime syndicates; the mass of the inhabitants of the city’s poorer districts, were illiterate, uneducated, and mistrustful of the local government, especially when it restricted food supplies and closed down markets.

Here, as in Hamburg and Saratov, cholera hit the poorest parts of the city hardest, reflecting insanitary and overcrowded living conditions and poor, usually shared water supplies; here too, as in all cholera epidemics, the usual pattern of mortality was reversed, with normally healthy age groups in their late teens, twenties and thirties being severely affected, so that excess mortality rates among these groups were extremely high; cholera made little difference to death rates among the very young and the old, but it made a huge difference to the youthful and the middle-aged, further stoking suspicions of poisoning among the poorer parts of the population.

Crowds forcibly freed victims being taken off to hospitals, attacked doctors, stretcher-bearers and policemen, pelting them with stones, chairs and even tables and benches, and even stopped workmen from lighting fumigation bonfires because they filled the streets with swarms of sewer rats. For most people, religious processions through the streets were the most persuasive way of fighting the disease.

A huge effort was made to win public trust through persuasion and education.

By 1910-11, however, the Neapolitan and national Italian authorities had learned the lesson of the 1884 disturbances. Instead of coercive policing measures, they formed sanitary squads consisting mainly of working men from the areas in which they operated, instructed them to use courtesy and persuasion and not force, and avoided alarming publicity. The sale of food on the streets was banned, wells and cisterns were sealed, sewers were disinfected, the water supply was monitored, swimming in the harbour was stopped, the streets were swept, the homes of victims were cleaned and their clothes destroyed; but a huge effort was made to win public trust through persuasion and education, and indeed after some initial resistance, there was widespread popular acceptance of these measures, as there had been in Hamburg in 1892.

Suspicion of medicine was not, however, confined to the nineteenth century or earlier eras. A recent major epidemic of cholera has occurred in Haiti, where the state is weak and disorganized, the population poor, educational standards low, and a major earthquake early in 2010 followed by a devastating hurricane had left one and a half million people homeless.  The disease broke out in October 2010. By February 2011 over 120,000 people had been hospitalized with cholera, which had affected nearly a quarter of a million people, with more than 4,500 deaths. Morbidity was running cumulatively at 23.5 per 1,000 inhabitants, reaching nearly 40 per 1000 in some districts.

The spread of the disease was intensified by poor sanitation in the camps set up for earthquake victims, only around half of which (600 out of 1,152) had latrines. Water supplies were inadequate or unhygienic and the resources and organization to provide clean water and proper waste removal facilities were lacking, with the result that the epidemic is continuing, with 700,000 cases recorded by August 2015 and 9,000 deaths overall.

In November 2010 the popular belief that the disease had been imported by a UN peacekeeping mission present in the country led to attacks on UN troops, especially from Nepal. There had been around 12,000 UN peacekeeping forces in the country since 2004, following violence accompanying elections and the effective disbanding of the country’s army and police. The UN’s stabilization mission or ‘MINUSTAH’ was engaged in training up a local police force and maintaining security but had little contact with the population and played little or no role in dealing with the consequences of the earthquake. It was widely seen as propping up a generally hated government and the belief that it had brought cholera to Haiti was another expression of the widespread popular distrust of the force.

As the political temperature heated up with approaching elections, crowds threw stones at the UN mission, burned tyres and blockaded roads, preventing cholera medication from coming in to affected areas. UN aid workers were attacked because of their association with the stabilization force, which was seen by some sectors of the population as an occupying army. The riots died down, leaving five people dead, many injured and serious damage to property, but they provided another example of how popular disturbances could be triggered by an insensitive approach to a desperate local situation.

At the same time, while the UN initially denied the allegations, medical investigation eventually proved that the strain of cholera present in Haiti was an Asian variant previously unknown in the Americas, and the link with the Nepalese soldiers seemed proven beyond reasonable doubt.

UN Peacekeepers, Haiti. Demotix/Tommy Trenchard. All rights reserved.By the time of the Haiti epidemic, cholera had been known to medical science for 120 years and there was general agreement about its causes, prevention and treatment. For much of the nineteenth century, however, medical opinion was divided over the causes of epidemic disease between ‘miasmatists’ and ‘contagionists’ and there was no effective prevention and treatment. Nineteenth-century medical science got very good at working out what caused diseases, but it had little success in working out how to cure them. For this reason, its popular legitimacy wasn’t very high.

By the late twentieth century, the public prestige of medicine had grown substantially. As a result, educational efforts, careful implementation measures and a more widespread popular belief in the legitimacy of science had reduced hostility. Nevertheless, in some areas, dissident medicine and alternative medical beliefs have still gained some currency. This was above all the case with the African National Congress in South Africa, which saw the AIDS epidemic that began under apartheid in the 1980s as the product of a plan by the white-supremacist South African government to reduce the numbers of the black majority population, in an obvious parallel to the suspicions articulated in nineteenth-century European cholera riots.

The lack of any effective treatment, and the widespread publicity given to a small number of medical scientists who denied the connection between HIV and AIDS allowed these suspicions to harden into a political decision to reject the first effective therapy – AZT, made available in 1998 – as an expensive confidence trick by drug companies and agents of ‘western medicine’. Until its patent expired in 2005, AZT was indeed expensive, and brought its manufacturers considerable profits, though it was also early on shown to be effective.

Once Nelson Mandela was replaced by Thabo Mbeki as President, the ANC government’s identification with AIDS denialism became complete, with the Health Minister advocating the use of garlic, beetroot and lemon juice as treatment and encouraging a wide variety of alternative therapies. Mbeki claimed AZT was a poison that caused deformities in babies and refused to allow its distribution, calling together instead a scientific advisory panel on AIDS consisting almost exclusively of hard-line denialists including some who claimed AZT actually caused AIDS.

For Mbeki and his supporters, the idea that AIDS was spread by sexual contact was an expression of western stereotypes about African sexuality. Yet his dismissal of “western” medical science was not backed by many of the ANC’s supporters, such as the powerful trade union movement, and it was widely ridiculed in the press, particularly after the South African delegate attempted to justify the government’s position at a World AIDS Conference. Mbeki’s stance had a good deal to do with his reluctance to lose prestige by admitting he was wrong.

The result was that AIDS spread unchecked in South Africa until in 2007 the number of South Africans with AIDS reached an estimated 5,700,000.

The result was that AIDS spread unchecked in South Africa until in 2007 the number of South Africans with AIDS reached an estimated 5,700,000 or 12 percent of the population, the largest number in any country in the world, with the next five highest rates of HIV/AIDS all borne by countries in southern Africa as well. More than 300,000 people were dying of AIDS each year in the mid-to-late 2000s, while in KwaZulu-Natal province the rate of infection in women who attended antenatal clinics was 40 percent.

Massive pressure by the international medical community had no impact on Mbeki’s views, but succeeded in persuading the cabinet to transfer responsibility for the issue to the deputy president, while the health minister’s absence through illness put her non-denialist deputy in charge, resulting in a new plan to take effective action. The proportion of South Africans with advanced HIV/AIDS who received anti-retroviral treatment increased from a mere 4 percent in 2004 to 28 percent four years later. However, when the health minister returned, her deputy was sacked and the plan put into reverse, and it was only with the defeat of Mbeki in the 2008 election and the replacement of his health minister that the government’s position began to change.

Once more, particular political circumstances were at work in determining reactions to a major epidemic. As new epidemic diseases strike, whether it’s cholera in the nineteenth century or AIDS in the twentieth, scientific opinion is initially uncertain and often divided. Governments and politicians are frequently driven to choose the science that best serves their interest, or their ideological standpoint. By the late twentieth century this was made easier by the growth of the popular press and then the internet, where minority opinions flourish and a good story can be made from science, or pseudo-science, that proclaims its dissent from the mainstream.

When government is carried out in the interests of a small minority, as in nineteenth-century Hamburg, where it is remote and authoritarian, as in Saratov, or where it is inefficient and corrupt, as in Naples in the 1880s, or where it fails to provide proper hygiene and sanitation, as in Haiti in our own time, or where drug companies stand to make major profits by charging high prices for patented medicines that are initially at least less than wholly effective, as in the case of AZT in South Africa, there is good reason for public distrust of the measures it takes and the advice the medical profession gives it.

Mistrust of medical science is thus not merely a product of ignorance: it also depends on the way the state treats people in a medical emergency and the way medicine, taken in its broadest sense to include public health administration, drug manufacture and so on, approaches the general public and its political representatives.