HISTORY 17 - Pandemics That Changed History

Inspired (if that’s the appropriate word) by the current COVID-19 Pandemic, I decided to write about the history of pandemics.

"The plague in Rome"  painted in 1869 by Jules Elie Delaunay creates an allegorical representation of the scourge breaking down doors.

A pandemic is an epidemic of infectious disease that has spread across a large region, for instance multiple countries, continents, or worldwide, affecting a substantial number of people.  Communicable diseases existed during humankind’s hunter-gather days, but the shift to agrarian life 10,000 years ago created communities that made epidemics (widespread occurrences of an infectious disease in a community at a particular time) more possible.  Malaria, tuberculosis, leprosy, influenza, smallpox and others first appeared during this period.  The more civilized humans became, building cities and forging trade routes to connect with other cities, and waging war with them, the more likely a pandemic became. Finally, as international business established and transportation for business and travel exploded across the globe, the prospects of pandemics further increased.

After reviewing source material available on the web, I decided to focus on those pandemics that greatly affected the history of the world.  I found two basic articles from which I’m stealing liberally: “Pandemics that Changed History,” by History.com editors; and “The History of Pandemics,” by Nicholas LePan. 

My approach is to select a Top 10 pandemics list from the many more listed in the history.com article - chosen on the basis of number of deaths and impact on history, and then to discuss each pandemic.  For completeness, I will then list other pandemics and the diseases that caused all the pandemics.  I will then talk about how we try to manage pandemics in term of reducing deaths and preserving hospital beds and equipment. 

Pandemics

The table below shows my choice for the ten most historically important pandemics, shown in historical order.  The number of deaths caused by infection diseases in our history is staggering!  The historical impacts range from periodically reducing the world’s population by stunning fractions, to geopolitical and societal changes that certainly affected our history.  

Following the table is a short discussion of each pandemic.

Top 10 Pandemics that changed history.

No.	Pandemic	Time Period	Disease/Cause	Deaths	Impact on History
1	Athens	430-426 BC	Typhoid Fever	75,000-100,000	Killed 1/3rd population of Athens.  Fatally weakened the dominance of Athens during Peloponnesian War.
2	Antonine Plague	165-180	Smallpox or Measles	5M	Weakened Roman Empire and claimed Co-Emperor Lucius Verus.
3	Cyprian Plague	249-262	Smallpox or Measles	Unknown - 5,000 per day in Rome at peak	Severely weakened, almost ended, Roman Empire.
4	Justinian Plague	541-542	Bubonic Plague	30-50M	Prevented Emperor Justinian from reuniting Roman Empire.  Caused massive economic struggle.
5	The Black Death	1347-1351	Bubonic Plague	200M	Killed 1/3rd of world’s population.  Ended England-France war.  English feudal system collapsed.  Halted England’s exploration of North Africa.
6	Columbian Exchange	1492-early 1600s	Smallpox, Measles, Bubonic Plague	56M	Up to 90% of Native Americans in the New World, having had no exposure, died as the result of exploration, takeovers, and settlement by Europeans.
7	Cholera Pandemics 1-7	1817-1975	Cholera	42M+	Started in India.  British Empire’s navy spread disease to Spain, Africa, Indonesia, China, Japan, Italy, Germany, America.  Subsequent pandemics spread it worldwide, affecting social and economic structures, and causing panic.
8	Third Plague	1885-1960	Bubonic Plague	15M	Started in China, moved to India and Hong Kong.  Used as excuse for repressive British policies, leading to revolts.
9	Spanish Flu	1918-1919	H1N1 Influenza virus	50M	Started in Europe, U.S., Asia – swiftly spread around world.  Killed more people than WWI.
10	AIDS	1981-present	Human immunodeficiency virus (HIV)	25-35M	Originated in Africa.  First observed in American gay communities, now worldwide.  Major impact on safer sexual practices and blood-borne infections.

Athens (430-426BC).  Earliest recorded pandemic.  Passed through Libya, Ethiopia, and Egypt, then crossed the Athenian walls as the Spartans laid siege.  Killed a quarter of Athenian troops. Virulence of the disease prevented its wider spread; i.e. it killed off its hosts at a rate faster than they could spread it.  Symptoms included fever, thirst, bloody throat and tongue, red skin, and lesions.  

Antonine Plague (165-180).  Possibly an early appearance of smallpox.  Started with the Huns invading the Roman Empire.  Huns then infected the Germans, who passed it to the Romans; then Roman troops returning from the Near East spread it throughout the Roman Empire.  Named after Roman Emperor Marcus Aurelius Antonius. Killed a quarter of those infected.  Caused up to 2,000 deaths a day in Rome.  Symptoms included fever, sore throat, diarrhea, and if the patent lived long enough, pus-filled sores.  

Cyprian Plague (249-262).  Possibly starting in Ethiopia, is passed through Northern Africa into Rome, then on to Egypt and northward.  Named after its first known victim, the Bishop of Carthage.  5,000 people a day were said to be dying in Rome.  City dwellers fled to the country to escape the infection, but instead spread the disease further.  Caused widespread manpower shortages for food production and the Roman army, severely weakening, and nearly ending, the Empire.  Symptoms included diarrhea, vomiting, throat ulcers, fever, and gangrenous hands and feet.  There were recurring outbreaks over the next three centuries.  In 444 it hit Britain and obstructed defense efforts against the Picts and Scots, causing the British to seek help from the Saxons, who would soon control the island. 

Justinian Plague (541-542).  First reported outbreak of the bubonic plague.  Started in Egypt, then spread through Palestine and the Byzantine (eastern Roman) Empire, and throughout the Mediterranean.  Reportedly killed 10,000 people per day in Constantinople at its height, perhaps 40% of city’s population.  Plague went on to eliminate a quarter- to-half of human population of known world.  Changed the course of the Roman Empire, preventing Byzantine Emperor Justinian from reuniting the Roman Empire.   Created atmosphere for rapid spread of Christianity.   Recurrences over the next two centuries.  Caused Europe’s population to drop around 50% between 550 and 700.  Symptoms included enlarged and extremely painful lymph nodes, high fever, severe headache, and muscle aches.

The Black Death (1347-1351).  Second large outbreak of bubonic plague.   Started in Asia and reached the Mediterranean and western Europe in 1348.  Killed an estimated 20-30 million Europeans in six years, up to half of the population in the worst-affected urban areas. Responsible for the death of 1/3^rd of the world’s population.  England and France were so incapacitated that the countries called a truce to their war.  The British feudal system collapsed when the plague changed economic circumstances and demographics.  Ravaged population in Greenland; Vikings lost the strength to wage war against native populations, and their exploration of North America halted.  The first of a cycle of 100 plague epidemics in Europe that continued until the 18^th century.  By the 1370s, England’s population was reduced by 50%.  Same symptoms as Justinian plague.

Columbian Exchange (1492-early 1600s).  Starting with the arrival of the Spanish in the Caribbean in 1492, through the early 17^th century, European explorers and conquerors brought devastating infectious diseases to the New World of North and South America.  The Europeans passed smallpox, measles, bubonic plague, influenza and other diseases along to the native populations which had no previous exposure to them.  These diseases devasted the indigenous people, with as many as 90% dying throughout North and South America.  By the early 1600s, as many as 56 million native Americans had died.  Over the next 200 plus years, as the new Americans moved their settlements westward across North and South America, encroaching on Native Americans lands, additional thousands of Native Americans died from diseases.

Cholera Pandemics 1-7 (1817-1975).  Seven cholera pandemics occurred between 1817 and 1975. The first cholera pandemic occurred in the Bengal region of India, near Calcutta starting in 1817 through 1824. The disease dispersed from India to Southeast Asia, the Middle East, Europe, and Eastern Africa through trade routes. The second pandemic lasted from 1826 to 1837 and particularly affected North America and Europe due to the result of advancements in transportation and global trade, and increased human migration, including soldiers. The third pandemic erupted in 1846, persisted until 1860, extended to North Africa, and reached South America, for the first time, specifically affecting Brazil. The fourth pandemic lasted from 1863 to 1875, spread from India to Naples and Spain.  The fifth pandemic was from 1881–1896 and started in India and spread to Europe, Asia, and South America. The sixth pandemic started in India and was from 1899–1923. The seventh pandemic originated in 1961 in Indonesia, officially ended in 1975, but still persists today in developing countries. Symptoms included diarrhea, nausea and vomiting, and dehydration.  Cholera outbreaks have caused panic, disrupted the social and economic structure of affected countries, and impeded development.  

Third Plague (1855-1960).  Third major bubonic plague pandemic to affect Europe.  Started in Yunnan China during a mining boom and moved to India (where 10 million people died) and Hong Kong, then spread worldwide.  Colonial (British) India faced the most substantial casualties and the plague was used as an excuse for repressive government policies that sparked some revolt against the British.  The pandemic was considered active until 1960 when cases dropped below 200 per year.  The U.S. saw its first outbreak in 1900-1904 in San Francisco.  The experiences in India were formative in the development of India’s modern public health services.  Same symptoms as Justinian and Black Death plagues.

Spanish Flu (1918-1919.  Infected 500 million people around the world and caused 50M deaths.  Unusually high mortality rate for young adults.  Symptoms included cough, sore throat, runny nose, nasal congestion, and breathing problems.   Wire services reports of a flu outbreak in Madrid, Spain in the spring of 1918 led to the pandemic being called Spanish Flu.  Mass troop movements and close quarters during WWI caused it to spread and mutate faster.  Improved transportation systems made it easier for soldiers, sailors, and civilian travelers to spread the disease.  The flu threat disappeared in the summer of 1919 when most of the infected had either developed immunities or died. 

AIDS (1981-present).  AIDS is thought to have originated in West Africa in the 1920s, moved to Haiti in the 1960s, and then New York and San Francisco in the 1970s.  AIDS was first recognized by the United States Centers for Disease Control and Prevention in 1981 along with its cause – HIV infection.  In 2018 about 37.9 million people were living with HIV.  Current infection rates are as high as 25% in southern and eastern Africa.  AIDS destroys a person’s immune system, resulting in eventual death by diseases that the body would usually fight off.  Symptoms include fever, headache, and enlarged lymph nodes. 

The plague in Tournai, then part of France, 1349, as depicted in "The Annales of Gilles de Muisit."

An influenza ward at the Walter Reed Hospital in Washington DC on November 1, 1918.

Other generally-recognized pandemics are shown below, also in historical timeline order.

No.	Pandemic	Time Period	Disease-Cause	Deaths
11	Japanese Smallpox	735-737	Variola major virus	1M
12	Italian Plague	1629-1631	Bubonic Plague	1M
13	Great Plague of London	1665, 1666	Bubonic Plague	100,000
14	Fiji Measles	1875	Morbillivirus	40,000
15	Yellow Fever (U.S.)	Late 1800s-1906	Flavivirus	100-150,000 in U.S., 34,000 during Panama Canal construction.
16	Russian Flu	1889-1890	H2N2 Influenza virus	1M
17	Asian Flu	1957-1958	H2N2 Influenza virus	1.1M
18	Hong Kong Flu	1968-1970	H3N2 Influenza virus	1M
19	Severe Acute Respiratory Syndrome (SARS)	2002-2003	Coronavirus	770
20	Swine Flu	2009-2010	H1N1 Influenza virus	200,000
21	Ebola (Africa)	2014-2016	Ebolavirus	11,000
22	Middle East Respiratory Syndrome (MERS)	2015-present	Coronavirus	850+
23	COVID-19	2019-present	Coronavirus	253,241  and growing (05-03-2020)

To try to get some perspective on the almost unbelievable number of deaths due to infectious diseases, I listed below a few familiar wars along with their death statistics.  There have been many other wars in our history with comparable death numbers, particularly in China, and probably less familiar to most of us, that I did not include in this brief list.  It is obvious, that between pandemics and wars, the we humans have been repeatedly subjected to horrible setbacks.

The figure following the table shows how the world’s population has changed over time.  Note the impact on population growth in the era of deadly pandemics and costly empirical wars.

Selected wars with death rates comparable to pandemics.

No.	War	Time Period	Combatants	Deaths	Comments
1	Roman Wars	343 BC - 382	Rome vs Samnites, Carthaginian Empire, Cimbri and Teutones, Gallic Tribes, Celtic Tribes, Jews, Goths, Germans	4-8.5M	Sum of deaths in all Roman wars as recorded by contemporary Roman writers.
2	Reconquista	711-1492	Spanish and Portuguese states vs Muslim states on Iberian Peninsula	7M+	Spanish and Portuguese finally drove Muslims from Iberian Peninsula that they had conquered in 710.
3	Crusades	1095-1291	Christians vs Muslims in Eastern Mediterranean	1-3M	European Christians tried to recapture the Holy Land, were initially successful, but eventually were driven out.
4	Mongol conquests	1206-1368	Mongol Empire from Central Asia vs Eastern/Central European states	30-40M	Mongols invaded Europe several times, were initially successful, but were eventually defeated.  Excludes deaths from Black Death pandemic.
5	World War I	1914-1918	Allied Powers vs Central Powers	16M	Central Powers surrendered.  Spanish Flu pandemic arose towards end of war.
6	World War II	1939-1945	Allied Powers vs Axis Powers	70-85M	Deaths include war crimes and holocaust.  Axis Powers surrendered.  Largest and deadliest war in history.
7	Korean War	1950-1953	South Korea and allies   vs North Korea and allies in Korea	1.5-4.5M	War ended with armistice separating North and South Korea.
8	Vietnam War	1955-75	Democratic South Vietnam and allies vs Communist North Vietnam and allies in Korea	2.4-4.3M	North and South Vietnam united under Communist regime.

Pandemics and wars dramatically affected the rate of the world's population growth.

Diseases

The infectious diseases that caused the 23 pandemics discussed above are listed in the table below, with a little more information about each disease.   Note that influenza and Coronavirus are shown to cause multiple diseases with variations of their viruses. 

Other important and deadly infectious diseases, not included in the table because they are not associated with pandemics, include chickenpox, leprosy, malaria, tuberculosis, and typhus. 

Infectious diseases that caused pandemics.

No.	Disease/  Pandemics	Cause-Source	How Transmitted	Comments	Status Today
1	Typhoid Fever    Athens	Salmonella typhi bacteria	Through contaminated food and water and close contact with infected people.	May have wiped out Jamestown colony in Virginia in early 1600s.  Many deaths in American Civil War and Spanish American War.	Vaccine (1896), sanitation, hygiene, and antibiotics have reduced death rate, but still 200,000 annual deaths worldwide.
2	Smallpox   Antonine?   Cyprian?   Columbian         Exch.	Variola virus	Inhalation of airborne virus from infected person sneezing, coughing, or prolonged direct contact.	Killed 400,000 Europeans per year in late 18th century.  During 20th century, killed 300-500M.   Worldwide eradication campaign began in 1967.	Vaccine (1796).  Only infectious disease to be eradicated.
3	Measles   Antonine?   Cyprian?     Columbian         Exch.	Measles virus	Inhalation of airborne virus from infected person sneezing, coughing, or direct contact.	First documented in 9th century.  Most contagious infectious disease. Before vaccine developed, U.S. saw 3M infections per year.	Vaccine (1963) -preventable, but still 240,000 deaths annually worldwide.
4	Bubonic Plague   Justinian   Black Death   Columbian         Exch.   Third   Italian              London	Yersinia pestis bacteria	Spread by infected fleas from small rodents. Person-to-person transmission from coughing, sneezing, or direct contact.	Isolated cases of plague still found in western U.S.	Vaccine still in development.  Virtually eradicated with rodent control and antibiotics.
5	Cholera   1817-1824   1826-1837   1846-1860   1863-1875   1881-1896   1899-1923   1961-1975	V. chorlerae bacteria	Spread mostly by unsafe food and water contaminated by human feces.	Killed tens of millions of people since it became widespread in 19th century.  Recent re-emergence in parallel with ever increasing size of vulnerable population living in unsanitary conditions.	Vaccine (1885), improved sanitation, and clean water have virtually eliminated disease in developed countries. Still relatively common in poor countries with crowded, unhygienic conditions - 120,000 deaths per year.
6	Yellow Fever   Late 1800s-    1906 (U.S.)	Flavivirus	Spread by the bite of a female Aedes aegypti mosquito.	Endemic to South America and sub-Saharan Africa.  Repeated U.S. epidemics in 18th and 19th centuries, imported by ship from the Caribbean.  Mostly in port cities, but spread up the Mississippi River in in 1800s.	Vaccine (1937) and reducing the population of transmitting mosquitoes have reduced deaths to 30,000 per year worldwide.
7	Influenza   Russian   Spanish   Asian   Hong Kong   Swine	Influenza virus  A   H2N2   H1N1   H2N2   H3N2   H1N1	Carried by wild aquatic birds, chickens, pigs, whales, horse, seals, and cats.  In humans, spread through air from coughs or sneezes, especially in cold dry air.  Also spread by touching surfaces contaminated by the virus and then touching the eyes, nose, or mouth.	Greek physician Hippocrates first described influenza in 412 BC. First influenza epidemic recorded in 1580 and recurred every 10 to 30 years.	Yearly vaccination, with new vaccines (first in 1938) developed twice a year as the influenza virus rapidly changes, have prevented pandemics, but seasonal flu (Influenza virus B) still accounts for 500,000 deaths per year worldwide (80,000 in U.S. in 2018/2029).
8	HIV/AIDS   1981-         present	Human  Immuno-    deficiency virus	Believed to have developed from a chimpanzee virus from West Africa in the 1920s.  In humans, spread primarily by unprotected sex, contaminated blood transfusions, hypodermic needles, and from mother- to-child during pregnancy, delivery, or breastfeeding.	Remains one of the world’s most significant public health challenges, particularly in low- and middle-income countries.	No vaccine yet.  Treatments exist to slow progress of and reduce death rate of disease.  Education, safe sex, and use of sterile needles remain the only prevention measures.
9	Coronavirus      SARS   MERS   COVID-19	Coronavirus types   SARS-Cov   MERS-Cov   SARS-CoV-2	Coronaviruses originate from bats. Humans spread viruses through air from coughs, sneezes, or talking; also, by touching contaminated surfaces and then touching the eyes, nose, or mouth.	COVID-19 originated in Wuhan, China in late December 2019.  Ongoing worldwide today.	Currently no vaccines that prevent SARS, MERS, or COVID-19.  Diseases managed by isolation, quarantine, masks, social distancing.
10	Ebola   2014-2016	Ebolaviruses	Spreads through contact with infected blood and body secretions.	Ebola is a viral hemorrhagic (bleeding) fever.  Symptoms include fever, sore throat, muscular pain, and headaches, followed by vomiting, diarrhea, and rash, leading to decreased function of liver and kidneys.	No vaccine or cure yet exists.

Pandemic Management

The basic strategies to control a pandemic are containment and mitigation.  Containment may begin in the early stages of the outbreak, including contact tracing and isolating infected individuals to stop the disease from spreading to the rest of the population, and therapeutic countermeasures such as vaccinations which may be effective if available.  When it becomes apparent that it is no longer possible to contain the spread of the disease, pandemic management will move to the mitigation stage, in which measures are taken to slow the spread of the disease, and mitigate its effects on society and the healthcare system.  In reality, containment and mitigation may be undertaken simultaneously.   

A key part of managing an infectious disease outbreak is trying to decrease the epidemic peak, known as (the now familiar) "flattening the curve." This helps decrease the risk of health services being overwhelmed, and provides more time for a vaccine and treatment to be developed.  In the COVID-19 pandemic for instance, these actions include: personal preventive measures such as frequent hand washing, wearing face-masks, and self-quarantine; community measures aimed at social distancing such as closing schools and cancelling mass gatherings; community engagement to encourage acceptance and participation in such interventions; and environmental measures such as cleaning of surfaces.  More extreme long-term measures include stringent population-wide social distancing, home isolation of cases, and household quarantine.  As time goes by, and more and more people develop antibodies, the population is less vulnerable as a group, and the infection rate decreases.

As I write this, we are right in the middle of COVID-19 pandemic, with all of the actions above being applied and vaccines in development. We will have to wait to see how it all works out.

The practice of quarantine began during the during the Black Plague in the 14th century in an effort to protect coastal cities. Cautious port authorities required ships arriving in Venice from infected ports to sit at anchor for 40 days before landing - the origin of the word quarantine from the Italian “quaranta giorni,” or 40 days.

Here are the quarantine regulations applied in Yuma, Arizona during the Spanish Flu Pandemic in 1918.

This is how the "flattening the curve" approach is supposed to work.

Conclusions

History shows that past pandemics have reshaped societies in profound ways. Hundreds of millions of people have died. Empires have fallen. Governments have cracked. Generations have been annihilated.

For the future, urbanization in the developing world is bringing more and more rural residents into denser neighborhoods, while population increases are putting greater pressure on the environment. At the same time, air traffic (except for the current pause) is increasing dramatically. These macro trends are having a profound impact on the spread of infectious disease.

This poem by Catherine O'Meara was written a few weeks ago to celebrate those who have to stay at home during a pandemic.