Wednesday 4 March 2020

The Plague a snapshot, 3,000 BC till today

Plague, a very brief History
Imagine if you will an illness that could easily spread from person to person and result in death within a couple of days. An illness that could spread through a city like wildfire and (during the Black Death) kill 60% of population. In some areas it was 80 percent and whole areas were depopulated as the few survivors fled. A few areas were relatively spared and while some of this was understandable, some of it was completely inexplicable, as if the disease was striking at random.
Mass Grave 1720-21 Epidemic, France
Nowhere was safe. It could cross city walls. Contact with a victim was not needed.It was an enemy that became simply known as 'The Pestilence' or 'The Plague'.
“They died by the hundreds, both day and night, and all were thrown in ... ditches and covered with earth. And as soon as those ditches were filled, more were dug. ...I ... buried my five children with my own hands ... So many died that all believed it was the end of the world.” Agnolo di Tura (14th century, Sienna)
Plague in humans has been detected both in Europe and Central Asia as far back as 5,000 years ago, suggesting it was already widespread by that time. While the Bronze Age had already started in Mesopotamia, it would take another 500 years to reach these regions technically this was still in late Neolithic times.
There were three massive pandemics of 'plague' in recorded history and the likelihood of a Pandemic in prehistory. Added to that, there were countless localised epidemics. 
A prehistoric Pandemic. In the first blog, I talked of the evidence emerging that a primitive form of plague caused the near extinction of the first Neolithic farmers in Europe, not long before the arrival of Indo-Europeans (see here).
The Justinian Plague was the next pandemic (541–542 AD) coming from Egypt. It is said to have killed 13–26% of the population of the middle east, Europe and Northern Africa. Some historians think it might have killed more than that.
The Black Death. (1347 to 1351 in Europe) is the most famous pandemic of all and the worst pandemic ever encountered. It is described as  “the Greatest Catastrophe to ever visit mankind” (Ole J. Benedictow)
Spread of the Black Death (Flappiefh, Wiki)
Siege of Kaffa. Most accounts start with Gabriele de’ Mussi’s classic account of the siege of Kaffa (Caffa). Kaffa (modern day Feodosia) on the Crimean coast was bought by the Genoese off the Golden Horde in 1266 and it (along with other settlements and enclaves) allowed them to dominate the trade throughout the Black Sea region.
Associated with river traffic (e.g. Danube, Dnieper, Dniester, Don and Kuban Rivers) it allowed them deep access into the hinterland, which included lucrative trade with the heart of Mongolian (Mongolian/Turkic) occupied Russia. It became one of the worlds most celebrated ports and one of Europe’s largest slave markets.
In 1307 Toqtai Kahn expelled the Europeans (after a year’s siege) for trading in Turkic slaves, but they were invited back by his successor and they built bigger and stronger than ever. In 1343 there was a religious brawl in Kana near Constantinople where a Moslem was killed. The ‘perpetrators’ (and a great many others) fled to Kaffa. The people of Kaffa refused to hand them over to the Moslem authorities but now they faced Jani beg, a proud and militarily aggressive  Kahn with a large army. He besieged Kaffa  in 1343, but was defeated by an Italian expeditionary force in February 1344. He returned in 1345 for another year and Gabriele de’ Mussi takes up the story:
“Oh God! See how the heathen Tartar races, pouring together from all sides, suddenly invested the city of Kaffa and besieged the trapped Christians there for almost three years. There, hemmed in by an immense army, they could hardly draw breath, although food could be shipped in, which offered them some hope.
“But behold, the whole army was affected by a disease which overran the Tartars and killed thousands upon thousands every day. It was as though arrows were raining down from heaven to strike and crush the Tartars’ arrogance. All medical advice and attention was useless; the Tartars died as soon as the signs of disease appeared on their bodies: swellings in the armpit or groin caused by coagulating humours, followed by a putrid fever.
“The dying Tartars... lost interest in the siege. But they ordered corpses to be placed in catapults and lobbed into the city in the hope that the intolerable stench would kill everyone inside. What seemed like mountains of dead were thrown into the city, and the Christians could not hide or flee or escape from them, although they dumped as many of the bodies as they could in the sea. And soon the rotting corpses tainted the air and poisoned the water supply ... one infected man could carry the poison to others, and infect people and places with the disease by look alone.”
He goes on to describe that the fleeing sailors took the plague to the European ports.
" Alas! our ships enter the port, but of a thousand sailors hardly ten are spared. We reach our homes; our kindred and our neighbours come from all parts to visit us. Woe to us for we cast at them the darts of death! Whilst we spoke to them, whilst they embraced us and kissed us, we scattered the poison from our lips. Going back to their homes, they in turn soon infected their whole families, who in three days succumbed, and were buried in one common grave.”

His compelling account, some of which is written in the first person has become part of established dogma even through to today. Historical documents show him to be in Sienna,  not in Kaffa, at the time of the siege and there are just too many contradictions for his account be accepted.
While the besieging Mongols may not have known that throwing corpses over the wall  would not be very effective, they didn't need to do it, rats would have breached the city fortifications and the plague would already be raging throughout the city. Muslims would not disrespect their own dead in this way.
It is true that the Crusaders had catapulted the heads of Moslem (civilian) captives over fortress walls in the past, but whole bodies that had died of the plague? The highly paid contractors that built and maintained the ‘counterweight trebuchets’ would hardly agree to such grisly work.
The Plague spread from Crimea in a slower, step-wise fashion and took a year to reach Europe, which is not in keeping with de’ Mussi’s account.

However it gained entry, the Black Death is estimated to have killed 30% to 60% of the population of Europe and devastated the Middle East and Northern Africa,. It took 200 years and more for Europe’s population to recover.
Asia and the Black Death
The 'Black Death' pandemic originated in the North West China (1331). By 1393 census the population of China had dropped an incredible 50%. Of course, China was in considerable chaos at the time between plague, famine and rebellions that saw an end to the Mongol rule in China.
There was also massive depopulation all over the great Steppe as far as the Korean Peninsula. How India escaped this time is another puzzle.

The ‘Third Plague Pandemic’, starting in China in 1855, was the weakest of the three and faced the most effective response and yet ten million died in  the first onslaught in British India alone and a further 12.5 million over the next thirty years.
Recurrence is the rule.
In the three historical pandemics, Plague didn’t rage through a community and then disappear. Characteristically there would be frequent highly lethal recurrences, becoming less frequent over time. The third Pandemic wasn't declared 'over' by the WHO till 1960 when world wide cases dropped to 200/ year.
In Britain the Black Death two years at first 1348- 1349 where it killed over 40% of the population. It returned in 1361–62, this time with 20% mortality. There were milder recurrences throughout the 14th and 15th centuries, the last outbreak being the Great Plague of London in 1665–66 which killed about a quarter of London’s population over an eighteen month period. 
The Justinian Plague 541–542 AD kept flaring up especially in the first 50 years, the last time being 750 AD. Evagrius Scholasticus from Antioch in Syria describes four recurrences in his life time. The first gave him bubonic plague while he was a school boy. Other recurrences caused the death of ‘several of my children, my wife, and many of my kin, as well as of my domestic and country servants’ . The fourth one was when he was fifty six and he lost “a daughter and her son”.
These recurrences didn't seem to be the emergence of a new strain, but from a re-infection of the local rodent populations. The Plague of those times remained dormant for periods in a way we don't understand even today.
Our forbears may have thought disease to be initiated by miasma (tainted air given off by rubbish and dead bodies), along with various supernatural explanations, but we shouldn't dismiss their intelligence or their powers of shrewd observation.
In an effort to deal with the frequent recurrences , a sophisticated and effective system of containment was devised. Isolation (to deal with leprosy) was well known since biblical times and in 1377 ‘quarantine’ was first introduced in Dubrovnik, where visitors had to wait in isolation for thirty days to make sure they didn’t have the plague before they entered the city.
Venice became foremost in developing systems to controlling spread, building the first plague hospital or 'lazaretto' 1423 on a small island and going on to perfect a system of maritime cordons. Merchandise from ships was unloaded to designated buildings. Procedures for so-called “purgation” of the various products were prescribed in minute bureaucratic detail; wool, yarn, cloth, leather, wigs, and blankets were considered the products most likely to transmit disease. Treatment of the goods consisted of continuous ventilation. Wax and sponge were immersed in running water for 48 hours.
The ship's captain needed to obtain a certificate of the sanitary status of a port of origin. He also needed to certify the health of his crew. Once there was an outbreak, a ship arriving from such a port needed to fly a yellow flag and lookouts were stationed on the church tower of San Marco to identify them.
The captain was taken in a lifeboat to the health magistrate’s office and was kept in an enclosure where he spoke through a closed window. If ordered to the quarantine station, passengers and crew were isolated and the vessel was thoroughly fumigated and retained for 40 days to see if cases would emerge.
The word "quarantine" originates from Italian quaranta giorni, meaning "forty days".
Why were the ancient ancient pandemics, so much worse?
Plague can be treated with antibiotics but even today, untreated Septicaemic and Pneumonic forms of plague are usually rapidly fatal, and even (untreated) the Bubonic form still has a terrifying mortality 30-40%. Transmission via infected material is not totally impossible but can be avoided by simple precautions, so most contemporary forms of plague do  
World wide distribution of Plague 1998
not carry much of a risk of person to person spread. “Uncomplicated bubonic plague is not contagious and patients do not place their family, other social contacts or care givers at risk”. New Mexico Dept of health 2013.
The Bubonic form almost always comes from a flea bite and the Septicaemic form (10-15% of cases) is most commonly a complication of the Bubonic form. Neither is particularly infectious (unless they spread to the lungs). It is only the uncommon Pneumonic form (usually 5% of cases) (and the very rare pharyngeal form) that are highly infectious.
The Pneumonic form is usually contacted directly or may be a rare complication of the Septicaemic form. Sometimes contemporary epidemics may involve a very high proportion of the especially dangerous Pneumonic cases, most likely when the infection is spread by close contact from other Pneumonic cases.
The role of rats (or another rodent) and their fleas was discovered in 1898 (Paul-Louis Simond) and remains the cornerstone of our understanding of transmission of contemporary plague but it is so persuasive and fits so well with our current (limited) contemporary experience that it is still unquestioned by many as the only significant means of spread of the common bubonic form.

Our contemporary experience does not explain previous Pandemics
 Contemporary experience does not explain the speed of spread, the (even greater) lethality, some clinical aspects and the much higher person to person spread seen in the first two 'historical' pandemics.
 In the past, this has caused some historians to question whether it was Y. Pestis or something else. Researchers have been able to show Plague DNA in the dental root canal of victims and while some descriptions of symptoms are ambiguous, many are not. So yes, it was Plague.
Were the reports exaggerated?
“Oh happy people of the future, who have not known these miseries and perchance will class our testimony with the fables”. Francesco Petrarca, Italian renaissance poet and scholar.
Poorer hygiene, poorer rat control and diet may have made our forbears more vulnerable. Recent research on  the so called ‘human flea’ suggests a new vector that could facilitate human to human spread, even of the Bubonic form.
Has 'Herd' Immunity Grown Greater?
While an individual who survived the plague only had partial immunity, Mihai Netea (at Radboud University) was able to show people from countries exposed to the Black Death had (over many centuries) evolved changes in their immune system that made them more resistant to the Plague.

Are we dealing with different strains that behaved differently? 
This is a rather a rhetorical question, because we know that different strains of Y.Pestis can have subtle and not so subtle clinical differences, they can differ biochemically and have differences in their plasmids, the significance of which we don't fully understand. 
 The most primitive form of plague in Neolithic times did not block the digestion of the rat flea and yet it seems to have been catastrophically devastating . One idea is that it had to be the far more dangerous Pneumonic form. In the first blog I discussed fleas that could transmit plague without being 'blocked'. Recent suspicion is directed at the (so called) 'human flea' which could result in human-to-human transmission without the need for rodents. We just don’t know.
The Italian writer Giovanni Boccaccio wrote 'the Decameron'. The background story is a small group that hides out from 1348 epidemic in Florence, and pass the time by telling amusing tales but he also describes his own observations of the disease:  “certain swellings in the groin or under the armpit ... soon after ...  black or purple spots appeared ... a certain sign of death.” 
This suggests that during the Black Death a large number of cases of the normal Bubonic form rampantly proceeded to the fatal septicaemic form.Reports of people coughing up blood might suggest some or even many of the septicaemic forms involved the lungs, making direct human to human transmission more likely and, of course, Pneumonic forms are very dangerous, spreading and killing quickly.
Not only were people of Europe and Asia more vulnerable to the plague, in the Justinian Plague, the Black Death and maybe in the Neolithic Plague they encountered particularly deadly strains that behaved somewhat differently.
Apart from the massive loss of life from these pandemics,  lethal recurrences and food shortages (e.g. England’s population declined from 7 million to 2 million in 1400) there were widespread social consequences. It is said that the Black Death contributed to the end of Serfdom in Western Europe.  The Justinian Plague was said to have prevented the Byzantines being able to hold their conquests in Italy and Northern Africa when they had tried to take back the western part of the Roman Empire. It may have aided the Anglo-Saxon conquest of England.

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