On August, 13, 1923, three Indian employees of the British India Steam Navigation Company fell ill at a camp by the river near Basra. Their illness caused violent cramps, vomiting, diarrhoea and rapid dehydration.
The disease spread rapidly, with devastating consequences. Five days after the first reports, 19 cases were recorded in Basra itself and seven of the victims died. Thirty miles downstream at the Persian city of Mohammerah, 133 cases were recorded, with a shocking 125 deaths.
Cholera was one of the first epidemics to break out in modern Iraq, spreading through contaminated food and drinking water. And the 1923 outbreak couldn’t have come at a worse time – it coincided with a mass Shiite pilgrimage to the holy sites in the south of Iraq, which only amplified the infectious potential of the disease, putting tens of thousands of lives at risk.
Because of the sheer number of people they can kill, pandemics can have a dramatic effect on the course of history. In the Middle East, the deadliest outbreaks have led to demographic collapses, shifts in power and the rise and fall of empires. Today, as COVID-19 rages through the region, what insights can we learn from historical outbreaks?
Shaping public health
Two years after seizing power in Iraq, the British Mandate was struggling with its response to the fast-moving 1923 cholera outbreak. Professor Omar al-Dewachi of Rutgers University, who has written a book on the history of healthcare in Iraq, explains that before the British invasion a decade earlier, Iraq had never seen a cholera outbreak (it was imported through war and increased trade and transport). However, the response to this epidemic in particular shaped how public health worked in Iraq for decades to come.
The initial response to the outbreak was ineffective – the Mandate imposed quarantines, barred travellers from Iran, and prevented the export of food that could be contaminated with cholera. None of these actions seemed to slow the spread of the disease, and, with a major pilgrimage about to begin, the threat to life was enormous.
The authorities were afraid of banning the pilgrimage outright, so, in a last ditch attempt to contain the outbreak, the newly created public health directorate imposed vaccinations on would-be pilgrims. Anyone who wished to make pilgrimage would need papers showing they had been inoculated. In the end, some 90,000 pilgrims were given the jab (out of 300,000 in the entire country). Ultimately, the Mandate’s statisticians recorded ‘just’ 1,640 cholera cases during the outbreak, and 1,100 deaths.
The decision to inoculate pilgrims was celebrated as a public health achievement. “It became a catalyst, so that after the epidemic, the authorities came to see centralized healthcare as the best approach,” recounts al-Dewachi. Prior to then, most healthcare in the Middle East was managed locally – health ministries had little power to centrally coordinate responses to disease.
Al-Dewachi, who himself worked as a medical doctor in Iraq in the 1990s, explains how this success against cholera became the blueprint for Iraq’s healthcare for the next 70 years. It became centrally organised and, at least until the 1990s, was recognised as one of the best systems in the region.
The 1923 cholera outbreak in Iraq shows how disease can shape public health strategies and the relationship between state and citizen. But go back a few centuries and historical disease outbreaks have had even more profound effects on the course of history.
Plagues and the ‘Golden Age of Islam’
The Golden Age of Islam, which historians date from around the 8th to the 14th century, saw many significant mathematical, theological, and scientific innovations emerge from the Muslim world, with learning and education centred around the Abbasid capital Baghdad. There are many reasons why this period of learning occurred, yet historians believe infectious diseases played an important role.
The Plague of Justinian, which struck Constantinople in 541-542 AD had a profound effect on the human population across Eurasia. From central Asia to western Europe and north Africa, millions of people died from the bacteria. It is believed that during its first wave about half the contemporary population of Europe died. The disease resurfaced several times over the following two centuries.
“The demographic shocks and the slow recovery of the population afterwards were a key determinant of labour market outcomes and long-term changes in the purchasing power of wages,” says Professor Maya Shatzmiller of Canada’s Western University, who has investigated the impact of this disease on economic outcomes in the Middle East.
The sheer number of people killed by plague meant that survivors could negotiate higher wages in return for their work. “The average incomes and purchasing power of unskilled wages in the region fluctuated but mostly remained within an interval that ranged from two to three times the subsistence minimum.”
Now that labourers could command a higher wage for their work, they had more expendable income. As a result, “patterns of demand began to change from basic goods and necessities towards goods with the higher income elasticity of luxuries”. She describes how after the plagues receded “the cookery books from Baghdad include recipes for mutton, lamb, chicken and dairy – products which are more expensive to cultivate than grains.” Historical records also show how manufacturers of the time began to innovate in different industries – from shipbuilding to metallurgy to textiles and ceramics.
With people earning higher wages and spending more, tax revenues which funded education would also have risen during the Islamic Golden Age. “The explosion of intellectual creativity in Baghdad can hardly be explained without the changes in the economy,” argues Prof Shatzmiller.
Nomads, disease and the rise of empires
The rapid growth of the early Islamic caliphates made it one of the largest empires the world had ever seen, and it came to dominate a huge swathe of the planet in little over 100 years. “How is it that the armies of the first caliphates reached Tours in France so quickly, or southern Kazakhstan so fast?” asks Professor Uli Schamiloglu of Kazakhstan’s Nazarbayev University.
There are no doubt multiple reasons the caliphates grew so fast, yet Schamiloglu points out that “the sedentary empires” which had previously reigned over much of north Africa and the Middle East had been severely depopulated by plague.
Just like COVID-19, the plague was a disease that was closely tied to trade and urbanisation. Its worst outbreaks were in cities, where the fleas which spread the disease could move from one victim to the next with ease. By contrast, nomadic peoples were much less affected – their lifestyle was the original ‘social distancing,’ living far outside population centres. As a result, the nomadic armies of the first caliphates stayed large and healthy, and they were able to sweep relatively easily through a world weakened by disease.
The Middle East, like much of the rest of Eurasia was struck by a second wave of plague during the 1340s and 1350s known as the Black Death. As with the rise of the First Caliphate, “nomadic people were less affected by plague than those living in cities.” Osman, the first Ottoman emperor, was the leader of a once obscure nomadic society – yet after the plague, “the rivals of the Ottomans vanished,” says Schamiloglu, making it much easier for Osman to win military campaigns starting in the late 1300s.
In Constantinople, it brought the Byzantine empire to its knees. Schamiloglu says that before the Black Death, the city’s population was around 1 million, yet by 1453 (when Ottoman Sultan Mehmed the Conqueror overran the city), the population was as low as 40,000.
Historic parallels
“Since this current outbreak emerged, we are seeing all kinds of behaviour which seem truly medieval,” Schamiloglu believes. He describes the rise in behaviours which are seen time and again in history during pandemics – from increased expressions of religiosity to economic slowdowns to debates around how to bury the dead. Having spent his entire career studying historical pandemics, the professor says it is surreal to see the behaviours he has long read about in history books repeated on nightly news broadcasts.
Meanwhile, one of the more worrying trends during the COVID-19 outbreak has been the spread of disinformation about the disease and its causes. Al-Dewachi points out that the response to disease “speaks to how important trust is in the relationship between the state and the citizen.”
Until the 1990s, the Iraqi government’s medical facilities were world class and citizens trusted its advice. A strong state and trusted health ministry meant “you could have one narrative” about how to treat diseases. But in societies where government has lost people’s trust “everyone is an expert and there is so much confusion about the right way to respond” – an important lesson for governments tackling COVID-19 today.
Ultimately, COVID-19 may not be as severe as other disease outbreaks, yet history tells us that it will have many short- and long-term repercussions on societies across the Middle East and beyond.
by Len Williams
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