Plagues in World History (4 page)

14 y Introduction

I thereby aim in this book to make a unique contribution to the study of disease, by explaining how humans have had the power to change how disease affects them simply through how they view disease. Although my approach does take a page from the relativist school of disease historians, I am not talking here merely about efforts to redefine the concept of disease but rather about the very practical effects that cultural attitudes toward disease can have in allowing a society to either succumb to or triumph over disease epidemics. These cultural responses to disease are even more important now that modern society has come to realize its limitations in terms of being able to medically cure or thwart challenging new pandemics, such as AIDS. I also will seek in the following pages to go beyond the more obvious impacts humans can have on disease incidence, such as through medicine, imperialism, or bioterrorism, even though these inevitably will be part of the story.43

By no means do I claim to be opening up unheard of or unprecedented vistas in the history of disease. After al , it was Thucydides who first noticed how humans themselves could alter the course of a plague, such as by succumbing to despair at the very idea of getting the disease or by neglecting to nurse patients, thus hasten-ing or assuring their demise, even if he did not realize the larger implications of these observations.44 We all know, instinctively, that psychosomatic disorders can happen, willing ourselves into suffering simply by dwelling upon it. (Medieval doctors rather poetically diagnosed psychosomatic disorders as “accidents of the soul.”) But I do claim to be expanding considerably upon this idea of humans’

impact upon disease and to be addressing it in a more comprehensive way than ever before. Readers may also find that I am rather more hopeful than other recent writers about disease with regard to humankind’s future in fighting epidemics.

Obviously, then, how a society or civilization perceives disease determines how it will respond to it, whether this be at the popular level or at the level of au-thoritative elites, and in terms of al the manifestations of the various social, economic, political, religious, or artistic aspects of this response. But at the same time, I also believe that what the disease is matters, in terms of establishing a clearly recognizable, biomedical identity.45 Yet, the complexities of the historical evidence are such that some throw up their hands in despair of ever definitively identifying the epidemics of the past. Certain historians of disease now take the position that it is futile or even wrong to attempt to match up a historical epidemic with a modern definition of a particular il ness, on the grounds that the present “laboratory” understanding of disease based on the germ theory is so different from how our distant ancestors approached their own, elusive “plagues.”46

To my mind, this is nothing less than an intellectual cop-out, or perhaps defeatism, that is hardly justified by any supposed lack of concordance of symptoms. On the contrary, in some cases, particularly as the evidence becomes much

fuller beginning with the Black Death of the late Middle Ages, premodern doctors and other authorities writing on the subject are able to give quite convincing diagnoses of a given disease. The Moorish physician Ibn Khātima, who authored a plague treatise in February 1349, gives an impressive symptomology, complete with case studies, of the three forms of bubonic, pneumonic, and septicemic plague, while his predecessor, the ninth-century Persian doctor Muhammad ibn Zakariyā al-Rāzī (known as Rhazes in the West), is able to clearly differentiate between smallpox and measles through a detailed analysis of their respective symptoms. And it was the sixteenth-century Venetian physician, Girolamo Fracastoro, who was the first to name and identify syphilis, as well as typhus. But even when premodern observers describe symptoms that are fantastic or that little accord with the “scientific” diagnoses of nowadays, having an “objective” or “ontological” definition of disease may still be helpful in understanding how our ancestors approached the plagues of the past. For example, some medieval doctors describe the lymphatic swellings of bubonic plague as being red, yellow, green, or black in color, which they said signified the severity of the illness; the fact that modern observers of plague fail to notice this same phenomenon may indicate to some that medieval people were suffering from an entirely different disease.47 But a detailed reading of medieval plague treatises reveals that actually what this tells us is that medieval doctors were here relying on ancient authority, in this case, the
Prognostics
of Hippocrates, rather than on their own, firsthand observations in order to make a prognosis of the disease. The lesson to take away from all this is not that the Black Death was a different disease from modern plague but rather that medieval doctors had radically different notions of how to diagnose and treat symptoms than their counterparts of today.

Completely abandoning the positivist or ontological definition would thus needlessly deprive us of a valuable tool in our effort to write the history of disease. It may be obvious to say that each disease is unique, but what is less evident is that each disease has its own social/cultural dynamic in terms of how a society or civilization perceives and responds to it. This is no less a part of the “social construction” of disease than the relative values and norms of the culture upon whom the disease is acting. Together, both these forces could intersect to create some quite dramatic impacts in the course of the history of a pandemic. A good instance of this is how many late medieval doctors conceived of plague as a kind of “poison,” which seemed a product of both contemporary perceptions of the disease’s progress in individual victims, as well as populations at large, and pre-conceived notions that were inherited from the ancients. Combined with the unprecedented mortality of the disease, this rather unique conceptualization of plague undoubtedly contributed to scapegoating tendencies that attributed the Black Death to a human cause, whereby Jews, witches, the poor, and other per-16 y Introduction ceived enemies of society were believed to be deliberately spreading or prolonging an epidemic for their own nefarious purposes. To take a more modern example, AIDS was initially seen in the mid-1980s as a “gay plague” spread mainly by abrasive anal intercourse (gay-related immunodeficiency disease, or GRID), which led to homophobic responses in the workplace, among health insurers, and elsewhere. (At the present time, AIDS is primarily prevalent in sub-Saharan Africa, where it is spread overwhelmingly by
heterosexual
contact.) In both cases, we now know that these respective views of plague and AIDS were wrong, but this does not change the tragedy of their historical responses.

Likewise, a modern “laboratory” identification of a historical disease or pandemic, even if only speculative, may help illuminate some of the outstanding questions and conundrums posed by it. Identifying the Black Death with plague, for instance, while still controversial, would explain why many late medieval outbreaks were associated by contemporaries particularly with women, children, or the poor, since these demographic groups were more likely to live in domestic conditions that ensured close contact with rats and fleas. It would also help us to understand the importance of trade to medieval society, since this is the medium through which plague is usually spread. Moreover, recent advances in biomolecular archaeology—which attempts to recover the genetic material of disease pathogens in human remains that have been preserved under optimal conditions, such as encapsulated dental pulp—seem to hold out some promise for positively identifying epidemics of the past in the laboratory just as definitively as modern occurrences of disease.48

Readers should take note here that, as a consequence of all the above considerations, I deal in this book only with a “positivist” panoply of diseases, namely, those caused by the invasion of the human body by a known, identified microorganism. I therefore leave out a host of noninfectious diseases, such as those caused by vitamin deficiencies or psychological disorders, that may appear in other surveys. I do this because, even though the latter diseases are certainly impacted by human behavior, at the same time, they lack some of the essential criteria for studying human responses to disease, such as, most obviously, the nature of being infectious. In general, I have adopted three standards by which I have selected the diseases that are addressed in the chapters that follow: first, the disease must be, or at least must have been in the past, fatal for large numbers of victims, for there is nothing like the fear of death for eliciting a response from people. Second, the disease must have been, or still is, worldwide in its scope, in order to afford the opportunity to study contrast-ing responses to it among different cultures and societies. Third, the disease must have been exerting its virulence for a lengthy period of time, to observe evolving attitudes toward it.

In many ways, the topic of disease is ideally suited for a globally oriented world history textbook such as this one. Comparing how different civilizations throughout space and time have reacted to disease is perhaps the best means of recovering the lessons that disease has to teach. And these lessons have not always been learned or passed on, even by the best historians.49 But by exploring the complex interactions, primarily in cultural terms, between disease and humans, a “new history” of disease that combines and integrates the positivist and relativist approaches may be written, for which some historians have been calling.50

I believe that understanding the many ways in which we, as humans with our almost infinite variations of societies and cultures, have coped with disease (or not, as the case may be) is one of the most important lessons of history. This is no mere academic exercise. It is nothing less than a matter of life or death.

C H A P T E R 1

y

Plague

The disease known as “plague” may seem obscure to most people nowadays, but plague has been called the deadliest of all diseases,1 one that was responsible for perhaps the most lethal pandemic in all of history. And it is a disease that is still very much with us, even in a modern, developed country such as the United States, as John Tull and Lucinda Marker, a couple living in Santa Fe, New Mexico, found out in November of 2002. While Lucinda quickly recovered from her bout with plague, her husband, John, came down with a case of the disease that was so severe he was immediately put into a drug-induced coma that was to last for the next two and a half months, at the end of which John woke up to find both his legs amputated below the knee. John did survive plague, but barely; at one point, all his close family members were rushed to his bedside to pay what were thought to be their final respects. As John tells his tale, it’s clear that he’ll never forget his near-death experience with plague.2

Plague is a specific disease, which should not be confused with its other, more general meaning in which it refers to disease in the abstract. It occurs in three forms, depending on how the microorganism that causes the disease in all cases, a bacterium known as
Yersinia pestis
, invades and spreads within the body. Plague is fairly unique among diseases in that it can be spread by both an insect vector, a trait it shares in common with malaria and typhus, for example, and also by direct, human-to-human transmission, which likewise happens in cases of influenza, tuberculosis, and smallpox.

Bubonic plague is the most common and widely known form of this disease, in which fleas are responsible for infecting hosts when they bite and attempt to 19

20 y Chapter 1

feed on their host’s blood yet are unable to do so because their stomachs are already “blocked” by a proliferating mass of bacteria, which they must regurgitate along with the blood meal back into the bloodstream of their victims.3 As its name implies, the rat flea (
Nosopsyllus fasciatus
in Europe and
Xenopsylla cheopsis in Asia) typically spreads plague among fur-bearing rodents, such as the black rat (
Rattus rattus
), which are highly susceptible to the disease, but once its animal hosts are dead and cold, the fleas will then jump onto any nearby hosts available, including humans. Keeping in mind that up to twenty-five thousand bacteria are injected into a host with each bite of a blocked flea, which can bite repeatedly as it ravenously attempts to feed; that each rat may host up to one hundred fleas on its body, all ready to seek a new host when necessary; and that hundreds if not thousands of fleas have been shown to be present in a home infested with rats, one can see how in some cases victims had so many bacteria introduced into their bloodstreams that they developed the far more virulent form of septicemic plague.4 As a matter of fact, Tull, who claims to be the only person in recorded history to have survived septicemic plague, was bitten by the same type of flea that had given a typical case of bubonic plague to his wife. Yet, in John’s case, the bubo on his groin was hardly noticeable and, instead of the bacteria becoming concentrated in the lymph glands, they seem to have turned inward and invaded nearly every organ in his body.5 How an individual body reacts to
Yersinia pestis in terms of being able to isolate the bacteria within its lymphatic system may also determine whether one develops a case of bubonic or septicemic plague.

In pneumonic plague, the bacteria enter the lungs after being breathed in, which typically occurs as the result of exposure to the expectorate, or airborne droplets, that have been coughed or sneezed out by an infected person. Therefore, direct human-to-human contagion is the norm in pneumonic plague, where no other animal intermediary is necessary, even though a pneumonic plague outbreak seems to start out as a secondary symptom of the bubonic form and tends to be localized, owing to the narrow window of time in which this form of the disease can be spread by the symptom of an infective cough. However, since the patient is usually well enough to travel during the incubation period, which in pneumonic plague can last up to three or four days (but in bubonic plague can last up to a week), it is possible that an outbreak of the disease in one locality then gives rise to another at a considerable distance away.6