Received: 25 January 2021 Revised: 26 March 2021 Accepted: 1 April 2021

DOI: 10.1002/jdd.12615

PERSPECTIVES

Pandemics and education: A historical review

Andrew I. Spielman DMD, PhD, MSc1 Gulshan Sunavala-Dossabhoy DDS, PhD2

1 Department of Molecular Pathobiology,

College of Dentistry, New York Abstract

University, New York, New York, USA
2Department of Biochemistry, Louisiana
State University Health Center,
Shreveport, Louisiana, USA
Correspondence
Andrew I Spielman, DMD, PhD, MSc,
Department of Molecular Pathobiology,
College of Dentistry, New York University,
New York, NY, USA.
Email: ais1@nyu.edu
Major pandemics have tremendous effects on society. They precipitated the early
decline of the Western Roman Empire and helped spread Christianity. There are
countless such examples of infectious diseases altering the course of history. The
impact of epidemics on education however is less well documented. This present
historical account of the past 800 years looks specifically at how some aspects
of education were shaped from the early medieval epidemics such as leprosy
and the Black Plague to the Spanish Flu and COVID-19. Leprosy changed reli-
gious education, and the Black Plague may have contributed to the rise of med-
ical schools, hospitals, public health education, and led to the implementation
of lazarettos and the quarantine. The smallpox epidemic helped usher in pub-
lic health education for immunization, while the 1918 Spanish Flu precipitated
the rise of education by correspondence, and recently COVID-19 has catapulted
remote digital learning to the forefront of higher education.

KEYWORDS
COVID-19, epidemics, health education, history of medicine, pandemics

1 INTRODUCTION impact on education in general and health education in

Prior to COVID-19, there were no studies looking at
the great epidemics that changed history and how they
impacted health education. In the case of dental education,
which started only 180 years ago, there have been only two
major pandemics that could have caused significant dis-
ruption: Cholera and the Spanish Flu. Furthermore, even
though formal medical education has existed for at least
900 years, pandemics and their effect on health education
have not been specifically chronicled.
During the past two millennia, great pandemics had a
devastating and disruptive effect on societies. For instance,
the Antonine Plague of 165 CE and subsequent epidemics
in the following centuries sped up the decline of the West-
ern Roman Empire and, due to the prevailing sense of
hopelessness and accompanying spiritual vacuum, helped
the rise of Christianity.1 The goal of the current review is
to look at the pandemics of the past 800 years and their
particular.
2 LEPROSY AND RELIGIOUS
EDUCATION
If one were to view a church sermon as a form of education,
the leprosy pandemic of the 13th century brought about
segregated religious services and the isolation of the sick
from healthy individuals.
Leprosy, or Hansen’s disease, was a consequence of
the Third (1189–1192) and Fourth (1199–1204) Crusades.
Knights and soldiers returning from Jerusalem spread
the disease across much of France, England, and the
Holy Roman Empire. By the early 1200s, the first epi-
demic erupted leading to the creation of leprosaria (leper
colonies). By 1220, Paris alone had 45 such colonies. They
were not regarded as prisons or detention facilities but

J Dent Educ. 2021;1–6. wileyonlinelibrary.com/journal/jdd © 2021 American Dental Education Association 1

2 SPIELMAN and SUNAVALA-DOSSABHOY
F I G U R E 1 A leper squint or hagioscope at St Peter and
Thomas Church in Stambourne, Essex, UK—Image is in Wikimedia
Commons, author Akabashi.
https://commons.wikimedia.org/wiki/File:
Ss_Peter_and_Thomas%27_Church,_Stambourne,
_Essex_-_North_Chapel_hagioscope_squint.jpg
rather as a way to protect infected individuals and society at
large. The Church viewed lepers as victims and the disease
as the visible manifestation of sin. As such, the Church
provided separate religious services for lepers. To ensure
sick worshipers could hear and see the pulpit during ser-
mons, they built either special windows, leper squints (also
known as hagioscopes, see Figure 1) inside the church, or
created a separate enclosed courtyard outside with an out-
ward facing pulpit. A number of these hagioscopes and
outside pulpits survive throughout Europe to this day.
3 THE GREAT PLAGUE, MEDICAL
EDUCATION, AND HOSPITALS
The Black Plague of 1346–1353 decimated Europe’s popula-
tion. Up to 60% of the population died leading to a shortage
of labor. As a consequence, demand for workers increased
along with their personal income. For many laborers, it
ended serfdom and ultimately led to the demise of feudal-
ism. For an overview of major pandemics, see Figure 2.
The Black Plague may also have had an effect on the
rise of hospitals and medical schools to impart knowledge,
share wisdom, and provide better treatment.2 Following
the epidemics in early Medieval Europe, medical schools
and hospitals were opened, many of them in the countries
most affected by the epidemics. Medical schools in Prague
(1348), Krakow (1364), Vienna (1365), Heidelberg (1386),
Padua (1399) were opened within a few decades after the
Black Plague. Thirteen more medical schools appeared in
the following century. Hospitals followed suit. Between
1200 and 1577, in Germany alone, 155 hospitals were estab-
lished. The appearance of hospitals and medical schools
led to an increased demand for medical texts. Naturally,
this was facilitated by the introduction of the movable
printing press in 1450 by Johannes Guttenberg.
Epidemics caused a serious disruption in commerce. To
reduce the impact in trading hubs like Venice, Florence,
and Ragusa, public health measures were introduced.
Ships considered to have infected cargo or personnel
were required to remain anchored in the harbor without
docking for 40 days. Hence the term quarantine (from the
Italian quaranta giorni). This rule was institutionalized
first in 1465 in Ragusa, and Venice followed suit in 1485.3
But even before that, in 1423 the Venetian government cre-
ated lazarettos, isolation colonies for the ill. These consti-
tuted a form of public health education, even though the
nature of contamination and transmission was unknown
for another 450 years. At the time the understanding of
infection was still based on the erroneous notion of spon-
taneous generation (abiogenesis) and the miasma theory.
By the end of the 15th century, Columbus’ expeditions
had brought syphilis to Europe from the New World. Ini-
tially, the disease was spread through the Franco-Italian
wars with resulting mutual recriminations as to which
side was to blame. The French called it the Italian dis-
ease (morbus italicus) while the Italians called it the French
disease (morbus gallicus). The epidemic forced authorities
to improve medical and public health education. In 1546,
Girolamo Fracastoro was the first to describe the conta-
gious nature of the disease in his classic treatise, De Con-
tagione et Contagiosis Morbis.4
4 THE GREAT PLAGUE OF LONDON
1665–1667 AND ISAAC NEWTON
In 1644, Leonard Lichfield, printer to Oxford Univer-
sity, published Physicall Directions in time of Plague, a
short pamphlet with common sense steps against the
SPIELMAN and SUNAVALA-DOSSABHOY
FIGURE 2 An overview of major pandemics and their impact on health education
plague using fresh air, cleanliness, and social distancing:
“Dwelling-houses are to bee kept clean, free from filth, and
ill smells, the Windows neere infected houses kept close with
glasse, or oyled, waxed paper, that light, but no infected ayre,
may come in. In houses farther from infection, windowes
open sometimes, to ward wholsome ayre and wind.” Unfor-
tunately, none of these steps prevented the Great Plague
of London two decades later. During the outbreak of 1665,
schools like Cambridge and Oxford were shut down. Isaac
Newton, then a student at Trinity College, Cambridge, was
sent home. He spent the next 20 months, from the sum-
mer of 1665 till the spring of 1667 at Woolsthorpe, north of
Cambridge. Without the potentially stifling influence of
some of his teachers, he had some of the most produc-
tive years of his life, generating works on the laws of
physics, gravity, and optics and establishing the mathemat-
ical branch of calculus. By 1666, Newton was considered
the preeminent mathematician in the world. Although an
apple did not actually fall on his head while sitting in
his garden during that summer, as legend would have us
believe, Newton’s observation of falling apples neverthe-
less gave him the idea for a universal law of gravity. The
year 1666 was consequently dubbed Annus Mirabilis: The
Wonder Year.6
5 PUBLIC HEALTH EDUCATION AND
THE PLAGUE
Not being able to understand the bacterial nature of pan-
demics in the 17th century caused people to employ bizarre
3
cures to ward off disease. These curious and largely ineffec-
tive habits were spread through public health education at
the time.
Eugenol and isoeugenol, ingredients found in modern
day interim dental restoration materials, have an intrigu-
ing connection to the plague epidemic of the 17th century.
These chemicals are found in clove (eugenol) and nut-
meg (isoeugenol), respectively. It was believed that wear-
ing small pouches around one’s neck filled with nutmeg
and/or clove could ward off the plague as a form of “chem-
ical amulet.” A public health pamphlet of the time, printed
by “Command from the Lords of the Councell” at Oxford
University, conveyed the following instructions: “Going
abroad, or talking with any [person having the plague], it
is good to hold in the mouth, a clove or two, a peece of
nutmeg[. . . ]; in the hand, a sponge dipped in vineger (sic)
and rosewater.6
Clove and nutmeg were rare spices in the 17th century,
which led to a lengthy war amongst the Portuguese, Dutch,
Spanish, and English for access to the islands where they
grew in order to establish a monopoly on their trade. In
particular, they vied for control of the Spice Islands of
Moluccas and Run in the East Indies (part of modern-day
Indonesia). Eventually, the Dutch succeeded in wresting
control of the trade routes and islands, first from the Por-
tuguese then the Spanish. After cementing their control by
suppressing local resistance, the Dutch finally made peace
with the English by concluding the Treaty of Breda in 1667.
Under its terms, the Dutch retained control of the island
of Run in exchange for ceding the island of Manhattan
to the British.7 So in a sense, eugenol, the source of the
4 SPIELMAN and SUNAVALA-DOSSABHOY
characteristic odor in dental offices today, is the reason we
speak English in New York and not Dutch.
6 PUBLIC HEALTH EDUCATION AND
SMALLPOX
At the end of the 18th century, a country doctor by the
name of Edward Jenner made the chance observation that
milkmaids in rural England who had been infected with
cowpox were immune to the more serious smallpox. Jen-
ner’s observation started a public health education cam-
paign for the need for mass inoculation exposing healthy
individuals to cowpox pus. He was aided by the wife of
the British Consul to Constantinople. In several letters
sent to her royal friends, Lady Mary Wortley Montagu
wrote about an immunization technique, long practiced in
the Ottoman Empire, very similar to Jenner’s. Her letters
brought the technique to the attention of the British Royal
Family, who after some initial trials on inmates (in return
for clemency) and children belonging to common peo-
ple, consented to immunize their own children. By 1840,
England established mass immunization. Elsewhere, pub-
lic health education spread with remarkable speed. When
Louis XV of France died of smallpox in 1774, it took the
French court only a year to institute mass immunization.
In 1776, George Washington ordered the immunization of
his entire army with the smallpox vaccine. In 1796, Edward
Jenner placed cowpox pus in a cut on the arm of an 8-year-
old boy named James Phipps who subsequently survived
smallpox thereby demonstrating the usefulness of vaccina-
tion.
7 PUBLIC HEALTH EDUCATION AND
THE 1854 BROAD STREET CHOLERA
EPIDEMIC
Cholera epidemics and pandemics appeared several times
throughout the 19th century. Starting in India, between
1816 and 1823, six pandemics swept across the globe. A
proper understanding of the disease and how it spread,
along with its causes and prevention gradually emerged
culminating with the work of Louis Pasteur and Robert
Koch. In 1854, London suffered an epidemic of cholera with
over 10,000 victims. Dr. John Snow, a local physician, man-
aged to trace the source of the epidemic to a contaminated
well on Broad Street in Soho. He convinced local authori-
ties to remove the handle of the well thus preventing the
spread of the disease. His meticulous work in contact trac-
ing is one of the tools epidemiologists and medical detec-
tives use today in public health education and prevention.8
8 SOCIAL DISTANCING
AND TUBERCULOSIS IN EARLY
20TH CENTURY
Social distancing in education was first suggested in the
early 20th century during an outbreak of tuberculosis
in the US. Students were moved to “open air schools,”
and classes were held even in freezing cold temperatures.
Schools in Providence, Rhode Island started a trend in
1908,9 a method that was subsequently used in 65 schools
across the US. The open air made a difference in the speed
of the recovery of students and also helped contain the
infection.
9 THE SPANISH FLU PANDEMIC OF
1918 AND THE RISE OF DISTANCE
EDUCATION
Epidemics become disruptive because the status quo can
no longer function. What was working prior to an epi-
demic suddenly becomes unsustainable or outright impos-
sible. This is true in education as well. Take the example
of distance education by correspondence and the 1918
Spanish flu pandemic. Although correspondence learning
was first used for a shorthand writing course in England
in 1840 by Sir Isaac Pitman as a curiosity, distance learn-
ing did not take off in earnest until the end of World War
I. At that point, the disruption caused by the 1918 Span-
ish flu coincided with the availability of extensive railway
networks and reliable postal service for delivery. This pri-
marily served disciplines that did not require regular face-
to-face activity such as law or philosophy.10 Over the next
few decades, as radio and television developed, additional
aspects of distance education became possible. In 1922,
Pennsylvania State College employed radio to broadcast a
course for the first time.11
10 COVID-19 AND HOME EDUCATION
Home education did not start with COVID-19. It goes
back to 1962 when NYU in collaboration with CBS offered
TV broadcast courses for credit. Both the quality of the
image and the bandwidth of information were limited.
It marked the rise of analog education. The personal
computer revolution in the 1980s, the appearance of the
internet in the 1990s, along with improvement in speed,
storage capacity, image processing, and sound technology,
ushered in the era of online digital learning. The University
of Phoenix became the first fully online degree-awarding
institution in 1989 and pioneered the concept of massive
SPIELMAN and SUNAVALA-DOSSABHOY
online open courses (MOOCs) featuring satellite virtual
classrooms for thousands of students at a time. By 2006,
89% of 4-year public colleges in the United States offered
some form of courses online.12 Despite advances in tech-
nology and reductions in cost, adoption of online educa-
tion had been sluggish. That is, until the outbreak of SARS-
CoV-2. Now it would seem that universities no longer have
any choice on whether to delay the implementation of an
all-encompassing online curriculum.
Hubei Province, China, is presumed to have been an
early center for the spread of SARS-CoV-2 in the latter half
of 2019. The zoonotic transmission of the new coronavirus
strain, though initially contained within the geographic
region like the SARS epidemic of 2003, spread rapidly from
human to human in an age where social interaction and
globalization are the norms. The virus soon reached the
US with the first cases of COVID-19 appearing in Jan-
uary 2020. However, it was not until March 2020 that the
rising number of infections, hospitalizations, and deaths
forced the suspension of in-person education. Seattle and
New York in particular were the first to see an exponential
increase in virus-positive cases and related fatalities. Not
since September 11, 2001, had such a disruption to everyday
life of this magnitude called for a nationwide adaptation to
a “new normal.”
Major shifts have occurred in nearly all aspects of edu-
cation during the lockdown, particularly at medical and
dental schools and clinics.13–15 Though didactic education
has largely transitioned online using available virtual plat-
forms, keeping the rigor and robustness of clinical pro-
grams ‘from a distance’ has posed unique challenges as
in-person patient care has dramatically declined. To main-
tain the health and safety of patients and care providers
alike, many clinical programs postponed elective surgeries
and suspended clinical rotations for students. Medical res-
idents have been parsed into smaller groups to work alter-
nating shifts to ensure social distancing. Telemedicine con-
sults have supplemented, and in some cases, supplanted
in-person clinical contact. Meanwhile, continuity of clin-
ical curricula has been maintained through teleconfer-
ence grand-rounds, small-group webinar discussions, and
flipping classrooms to allow asynchronous learning.16,17
Online archives of case reports that integrate relevant con-
cepts and databanks of clinical and radiological images
have fostered interactive learning and problem solving
while promoting competency and preparing both students
and residents for Board exams.17
Nevertheless, there remains an acute need to find solu-
tions to achieve and maintain technical proficiency. Sim-
ulation laboratories, including those based on virtual and
augmented reality, have to some extent filled this gap. As
clinical electives play a critical role in the decision to pur-
sue specialization, the Otolaryngology–Head, and Neck
5
Surgery Program at the University of Pennsylvania, for
instance, has introduced live-streaming of operating room
procedures with the ability to interact with the operating
team in real-time.18 It provides for a more immersive stu-
dent experience compared to other surgical programs that
have instead opted to use pre-recorded procedures to sup-
plement surgical knowledge.17 An online video library of
clinical skills and operatory procedures can be an excellent
educational resource in these times of limited patient inter-
action as well as a useful tool to augment learning in gen-
eral. The days of viewing surgeries through glass observa-
tion domes or peering over the shoulders of the operating
team members will be relegated to the past as digital plat-
forms become increasingly able to provide firsthand learn-
ing experiences. Naturally, electronic acquisition of patient
consent and HIPPA authorization during telehealth con-
sultations, and secure digital communications that safe-
guard patient privacy and maintain ethical standards are
all concerns that need to be adequately addressed as med-
ical education moves to online platforms. In addition to
remote examinations and research projects, there is a need
to explore innovations in clinical competency assessments
beyond the use of simulators.
In-person class attendance and clinical experience have
long been the cornerstones of traditional medical or den-
tal education. But the proliferation of technology during
the COVID crisis has transitioned medical education
from physical classrooms and clinics to virtual learn-
ing centers and health stations. Hastened by this current
pandemic, universities have been forced to embrace tech-
nology to a degree that would have been unimaginable
only a year ago. Indeed, there has been a steep learn-
ing curve for medical and dental schools in particular.
Such technology-driven solutions have changed health
education such that it is no longer so constrained by
scheduling, classroom size, and clinical operatory space.
Healthcare education has shifted to an individualized self-
paced curriculum that emphasizes evidence-based prac-
tice over organized knowledge and personal competency
over scholarship.
The full impact of COVID-19 is difficult to assess since
we are still adapting to it. In the span of only 9 months, 2924
articles (as of December 25, 2020) appeared on COVID-19
and education with 280 of those studies featuring those
two keywords in their titles. It is expected that far more
adjustments, efficiencies, and innovations will follow. Sim-
ilar to major pandemics of the past, the full effect will be
appreciated only from the vantage point of hindsight in
the ensuing years. One thing though can be stated with
certainty: the COVID-19 pandemic has achieved virtually
overnight what years of curriculum committee meetings,
institutional strategic planning, and nationwide reforms
could not.
6 SPIELMAN and SUNAVALA-DOSSABHOY
AC K N OW L E D G M E N T S
This study was not supported by outside funding agencies.
It was supported by institutional funds from NYU and LSU
for time and effort. The authors wish to thank Robert Spiel-
man for his editorial help.
CONFLICT OF INTEREST
The authors have declared no conflict of interest.
AU T H O R CO N T R I B U T I O N S
Andrew I. Spielman contributed with the concept, design,
research, and writing the segment related to the period
1200–2019 and edited the entire manuscript. Gulshan
Sunavala-Dossabhoy contributed with the concept, design,
research, and writing of the COVID-19 section and edit-
ing of the entire manuscript. Both authors gave their final
approval and agree to be accountable for all aspects of the
work.
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How to cite this article: Spielman AI,
Sunavala-Dossabhoy G. Pandemics and education:
A historical review. J Dent Educ. 2021;1-6.