In an increasingly interconnected and peaceful world, disease remains one of the greatest fears of the modern age, especially the outbreak of a ‘superbug’ from genetic mutation and antibiotic resistance. Despite the medical advances of our time, diseases such as Coronavirus or Ebola have spread across nations and have caused the deaths of thousands. Throughout history, outbreaks of diseases on a major and international level have been rare but at times disastrous, especially in the poor living conditions and medical standards of previous ages, often made worse by times of war or other hardship.
We find recorded several cases in history of particularly deadly diseases, which may be termed now as epidemics, but the cause, nature and extent of the diseases are difficult to discern.
Plague of Athens 430-426 BC
The first major account of an epidemic was the Plague of Athens in 430-426 BC, recorded by the eyewitness and survivor Thucydides in his The Peloponnesian War (2.49-54). The plague was facilitated by the Peloponnesian War, as a result of which many Athenians had crowded behind the city walls to wait out a Spartan siege. Thucydides reported that the plague spread from Ethiopia into Piraeus, the city port, a very international centre in the ancient world, that spread rapidly. Many possible diseases have been proposed as the cause: bubonic plague, smallpox, typhoid or an ebola-like disease. However, the truth remains a mystery. The death toll is estimated at 75-100,000 people or 25% of the city’s population.
Antoine Plague 165-80
Another major epidemic was the Antoine Plague, described by Galen, which struck the Roman Empire in 165-180 AD. It was first recorded in the Roman siege of Seleucia, in modern Iraq, and spread throughout the Empire as far as Germany and Gaul. The disease is thought to have possibly been either smallpox or measles and at its height killed 2,000 a day in Rome. The estimated death toll is 5 million. The disease may also have spread from Han China, where reports of a similar disease date from the same period. It may have spread along the Silk roads or via the Roman embassy of 166 to Vietnam. Even the thought of this, true or not, may have hampered trade relations between East and West which could have greatly changed history.
Bubonic plague has led to history’s most deadly pandemics, with three major and disastrous outbreaks, despite its relative rareness and preventability now. It is caused the bacterium Yersinia pestis which attacks lymph nodes, swelling to form painful ‘bubones’ which can turn black and burst. The bacterium can also cause pneumonic plague in the lungs and septemic plague in the blood. It is carried most often in fleas and infected small animals or flea-carrying animals, particularly rats. The bacterium is then transferred into the human body via bites or consuming fluids from an infected body. Symptoms include high fever, painful swelling of the lymph nodes, and if it spreads to other parts of the body leads to gangrene and blackening of limbs and facial features, vomiting, diarrhoea, coughing blood, delirium and death.
Plague of Justinian 541-2
The first major outbreak was in 541 affecting much of the Eastern Mediterranean and the Byzantine Empire. It was transmitted via rats that existed on the trade ships moving throughout the Mediterranean, especially grain ships travelling from Egypt to Constantinople, the capital of the Byzantine Empire. At its peak some estimates conclude there were around 5,000 deaths a day in Constantinople with 40% of the total population dying and that in total up to 25 million fell victim to the disease, a quarter of the population of the Eastern Mediterranean. However, more modern scholars have concluded on much smaller estimates. It was regarded as the first pandemic and had great effects on European history. The devastation in the Byzantine empire meant agriculture was ruined, with grain prices soaring, whilst tax revenue plummeted due a reduced population. Recent gains in Italy and around Carthage, briefly reuniting the Roman empires, were reversed as the Goths, Vandals and Lombards retook much Byzantine territory.
Black Death 1346-53
The deadliest outbreak of disease was the second major case of bubonic plague, commonly known as the Black Death. Likely originating in the East and China, the disease spread West along the Silk roads reaching the Black Sea and Mediterranean. Trade ships then spread the disease to the rest of Europe, hitting Italy first in Sicily and Venice in 1347, and the rest of Europe over the next three years. The disease would wipe out entire rodent populations, requiring repopulation before another outbreak would occur, recurring frequently over the next few centuries although never so badly. Estimations of a death toll are difficult but range between 75 and 200 million, 45-50% of the population and in the hot and connected areas of the Mediterranean, mortality rate was even higher. Populations would take years to recover and Florence not until the 19th century. The change in population changed the agricultural workings of many areas and the labour force reduced. Some even claim the decline in population led to a ‘mini Ice age’. Fanaticised and fearful, many blamed minority groups, especially Jews, resulting in many massacres, one at Strasbourg killing 2,000. This led many Jews to relocate to Poland where they were welcomed, leading to the large population there until the Holocaust during the Second World War.
Third Plague (Bubonic) Pandemic 1855-1960
The third major outbreak began Yunnan province on the Southern border of China, among the local rodent population. The influx of Han Chinese people to the area for mining, urbanisation, increased trade, and the Panthay rebellion which entailed refugee and troop movements, meant the plague spread rapidly throughout Southern China. Particularly damaging was the spread to the Canton area in 1894 and from there British-held Hong Kong, a centre of world trade and from where the plague spread to every continent.
In India, the plague was particularly severe due to the poor living conditions and packed urban centres of British imperial rule. Moreover, British measures to control the virus such as restriction of movement and the banning of Indian cultural medicines were seen as oppressive and culturally invasive and were hence disobeyed. 10 million died in India, and further 2 million died in the rest of the world. The World Health Organisation only declared the pandemic over in 1960. Bubonic plague still exists in much of the Chinese and East Asia rodent population. In 2019, a couple died of the bubonic plague after eating raw marmot in Mongolia.
Epidemics in the New World
The Spanish conquest of the Americas began with Mexico in 1519. The conquest was deadly in its sacking and massacring of cities, but far more so for the diseases it spread. A merchant ship to Hispaniola, an island in the Caribbean, first brought smallpox to American shores, against which the local population had no immune defence. It devastated the local populations. It reached Tenochtitlan in 1520. Bernard Dial, a Spanish chronicler, wrote “We could not walk without treading on the bodies and heads of dead Indians”. The death toll is estimated at over 5 million
On top of this, a native disease named Cocolitzli by the Aztecs led to millions of deaths. The disease returned several times, baffling native and Spanish doctors. Symptoms included high fever, black tongue, dark urine, dysentery, severe abdominal and chest pain, head and neck nodules, neurological disorders, jaundice, and profuse bleeding from the nose, eyes, and mouth. It usually killed within 3-4 days, leading to 5-15 million estimated deaths.
Subsequent Old World disease epidemics persisted in the Americas such as chicken pox, diphtheria, typhus, influenza, measles, malaria and yellow fever. A century after the arrival of the Spanish, some estimate over 90% of the New World population had died, the vast majority from disease.
Influenza, or ‘the flu’, is a common viral disease, which regularly mutates leading to the usual seasonal epidemics seen annually. A flu jab is developed annually to combat such mutations but due to the rapid changes in the virus, this will not be effective in subsequent years. Annually, there are three to five million cases of severe illness and about 290,000 to 650,000 deaths, usually in vulnerable groups such as the old, pregnant, or those with an existing health condition such as asthma or heart issues. Symptoms include high fever, runny nose, sore throat, muscle and joint aches, headache, coughing, and feeling tired. Complications can lead to viral or bacterial pneumonia, or bacterial infections in the sinuses that can spread throughout the body, as well as worsening previous health conditions.
These mutations are usually guarded to some extent by previous immunity among people. However, large influenza pandemics can occur when a new strain is developed in animals and spread into the human population. Their novelty means there is little to no immune protection existing in humans. The virus is spread rapidly between people in the air via droplets in coughs and sneezes or by touching contaminated surfaces. These pandemics occur when such a new strain infects human populations across the world, and occur irregularly, with 9 happening in the past three centuries.
Spanish Flu 1918-20
The deadliest pandemic was the so-called ‘Spanish Flu’ involving the H1N1 virus, the only Category 5 influenza pandemic, meaning a mortality rate of over 2% amongst those infected. It is unclear from where the disease originated, but crucially it did not start in Spain. The disease coincided with the end of the First World War, with fighting still ongoing. Participant countries censored press to minimise reports of the disease and maintain morale. Spain, however, was a neutral country, and so press covered the spread of the disease here accurately, making it seem as if Spain was suffering particularly, and so creating the name ‘Spanish Flu’.
The timing of the flu was particularly apt for facilitating a pandemic. War meant the focus of governments and press was on other matters. Similarly, large parts of Europe had been devastated and both civilian and military populations were weak. Large troop movements facilitated the spread. The virus also mutated resulting in a more virulent strain developing leading to an even more lethal second wave. The more lethal strain was also spread more than usual: in a usual flu, a mild strain still allows someone to work and so move about and spread the strain, whereas a more severe one will incapacitate and keep the sufferer at home, preventing transmission; in war the more mild sufferers remained at their posts and the more severe sufferers were transported to hospitals to transmit the virus.
The disease spread to all parts of the globe, will 500 million estimated to have been infected and 20-50 million estimated to have died as a result. The disease was particularly deadly in its higher mortality among the young population, whereas deaths from most flus occur disproportionately among the elderly. The death toll for the disease was higher than the First World War, and the deadliest since the Black Death, yet it received little impact in the arts of the time. Virginia Woolf wrote in 1926 in her essay ‘On Being Ill’: “English, which can express the thoughts of Hamlet and the tragedy of Lear, has no words for the shiver and the headache”. It did appear among the work of some artists of the time, and Egon Schiele’s ‘The Family’ has come to embody the disease. Schiele depicts himself, his wife, and daughter, all three of which would die from the illness before the painting could be completed.
Other Influenza Pandemics
There have been 8 other influenza pandemics in the last 300 years, although none have passed beyond a Category 2 pandemic i.e. beyond 0.5% mortality amongst those infected. The ‘Asian Flu’ of 1957-8 and the ‘Hong Kong Flu’ of 1968-9 were two particularly deadly outbreaks, spreading all over the world and both resulting in the estimated deaths of 1-4 million. Their victims were more typically prevalent in more vulnerable population groups, especially the elderly.
The most recent pandemic was the ‘Swine Flu’ pandemic of 2009-10, originating in Mexico. This pandemic likely infected, according to the WHO, 11–21% of the global population, or around 700 million–1.4 billion people. Mortality was no more than the usual seasonal flu, but the characteristic feature was that the elderly were not disproportionately affected, much like the Spanish Flu.
AIDS (acquired immunodeficiency syndrome) is caused by the infection by two species of Lentivirus, commonly known as the HIV (human immunodeficiency viruses). The virus is usually sexually transmitted, but also occurrs through the transmission of bodily fluids such as from mother to child
in pregnancy and breastfeeding or between people via the sharing of needles or blood transfusions. The virus results in flu-like symptoms 2 to 6 weeks after infection but can remain symptomless for many years after this, whilst still destroying the infected person’s immune system. Left untreated, the virus leads to the condition AIDS, describing when the individual is susceptible to a variety of diseases a healthy immune system would normally defend against. These include tuberculosis, cancers, and other ‘opportunistic infections’. This is the final stage and can quickly cause death if left untreated.
HIV is believed to have originated from chimpanzees in the Democratic of Congo, likely from the bushmeat industry. The disease was discovered in the USA in 1981, when an increasing number of gay men, but also a smaller number of injected-drug users, gained unusual diseases such as rare lung infection called Pneumocystis carinii pneumonia (PCP), usually only found in people with severe complications in their immune system. This led to the disease being initially known as ‘GRID’ (Gay Related Immune Deficiency).
As organisations struggled to identify the cause, transmission and treatment of the disease, over 2.5 million cases had been confirmed by 1993. In the US, the death rate began to slow by 1997. However, in Africa, where homosexuality was illegal in many countries and the existence of a large homosexual population not acknowledged and persecuted, politics hampered response. AIDS activists were often arrested due to the disease’s associations with the gay population. In 2003, over 40% of adults in Botswana had the disease. Heroin addiction in Asia also led to over 2 million cases in India alone. Response still improved but the current death toll still stands at over 32 million and is constantly rising. In 2018, there remained around 37.9 million cases, with 20.6 million of these in Eastern and Southern Africa.
No cure of HIV exists, but treatment via highly active antiretroviral therapy (HAART) can be very effective, and at present two people have been cleared of the disease.
The West African Ebola epidemic was a widespread outbreak of Ebola virus disease (EVD) in predominantly Guinea, Liberia and Sierra Leone. It is spread via the contact with the bodily fluids of those infected, and is now known, though not at the time, to be also sexually transmitted. The disease is a haemorrhagic fever causing fever, head and body aches, and a sore throat before developing into vomiting, diarrhoea, internal and external bleeding, and the decreased function of the liver and kidneys. The mortality rate was extremely high at somewhere around 40%, usually due to lack of fluid pressure.
Ebola outbreaks had happened before, but this 2013-6 epidemic was especially lethal as it spread out of isolated rural areas to the capital cities of the three affected countries. The poor health and surveillance systems of the area facilitated the spread of the disease. In total there were 28,646 cases, with 11,323 deaths. The impact of the epidemic had knock-on effects on other diseases by absorbing resources and damaging the healthcare workforce. In Liberia, 8% of doctors, nurses, and midwives died. This meant other diseases such as malaria, HIV, and measles grew worse. The Public Health Emergency of International Concern status was lifted by the WHO in March 2019.
COVID-19 is a disease caused by the Coronavirus. Symptoms are similar to the flu, including fever, cough, and shortness of breath which can lead to pneumonia, acute respiratory distress syndrome. The disease is caused by droplets often spread via coughing or the touching of contaminated surfaces or people. The disease was first discovered in Wuhan, China in December 2019. Many believe it originated in the Huanan wet market which sold live animals.
The severity of the pandemic is caused by the virus being especially contagious, the little immune defence to its novel form, and the fact it is asymptomatic for up to 14 days. The disease was spread via global travelling between countries and has been particularly deadly amongst the elderly generation. As of the 20 March there have been over 267,000 cases in 183 countries with over 11,000 deaths. But the majority (80%) of deaths have occurred in those over 60, and 75% in those with pre-existing conditions. Countries such as Italy, densely populated and with a high elderly population, have as a result been especially badly hit. Efforts to manage the pandemic have included quarantines, border closures, the closing of schools and universities, and the closing of bars, restaurants, cinemas and other social venues. The economic and social effect has been vast, with many businesses closing due to lack of business, and hysteria causing panic-buying and xenophobia, especially against Chinese individuals and businesses. The pandemic at the time of writing is ongoing and on the rise.
These epidemics were particularly impactful and frightening due to their fast and novel spread and the condensed nature of their effect. However, other diseases can be as deadly on a regular basis. There have been 7 Cholera pandemics, the worst being that of 1852-60 claiming over 1 million lives; there were 228 million cases of Malaria in 2018 with 405,000 deaths; over on quarter of the world’s current population have been infected with Tuberculosis and last year there were 8 million cases with around 2 million deaths. The threat of disease and epidemics has been a constant of life throughout the ages. And the current COVID-19 pandemic has shown the still real threat of epidemics to all nations even today.
By Wilfred Sandwell