The Antonine plague
Peste à Rome | Plague in Rome. (Jules-Élie Delaunay, Public domain, via Wikimedia Commons)
Evidence of smallpox has been found as far back as 1570 BCE in Egypt, but as will be seen, the existence of a disease is only one part of what it takes to make an epidemic. The earliest major smallpox epidemic was the Antonine plague, estimated to have killed 5–10 million people, between a quarter and a third of the Roman population.
The Antonine plague began during the co-regency of emperors Lucius Verus and Marcus Aurelius, as Roman soldiers returned through Mesopotamia from the Parthian war. (The plague gained the appellation Antonine after the emperors’ family name, Antoninus). Traveling towards Rome, soldiers left a trail of disease in their wake that would spread for nearly a century.
Upon the epidemic’s arrival in Rome, Galen, a renowned physician of the time, abandoned the city; the disease would ultimately kill all his slaves, who remained in the city. By some accounts, upwards of 2,000 people died every day in Rome alone. The epidemic would eventually claim the life of Marcus Aurelius and mark the beginning of the end of the Roman Empire.
Epidemics occurred roughly every 10 to 20 years in the Roman Empire, but the Antonine plague is unique for its scale and impact. Galen called this epidemic under Marcus Aurelius “the great plague,” but that term is often used to mean “pestilence” rather than a specific disease. The Antonine plague was likely caused by smallpox.
The Plague of Justinian
The Course of Empire: Destruction. (Thomas Cole, Public domain, via Wikimedia Commons)
In 476, the Western Roman Empire would collapse partly due to the expansion of Germanic tribes. However, the Eastern Empire would continue and, later, be known as the Byzantine Empire.
In 541, during the reign of Justinian, bubonic plague began to emerge throughout the Byzantine Empire, marking the beginning of the “first plague pandemic”. Likely transported by rats or ground squirrels in a shipment of grain from Egypt, the disease would reach Constantinople and eventually spread via trade routes around the empire.
The densely populated capital of the Byzantine Empire, Constantinople (today known as Istanbul), was severely affected and would see 10,000 people die per day. Roughly one fifth of the city’s citizens would die of the disease. It is estimated that by 590, 100 million people had died.
Japanese Smallpox Epidemic
'Hōsō taiji no zu' | 'Defeating smallpox'. (Shungyō, Courtesy of UC San Francisco, Special Collections)
Written accounts of smallpox date back to as early as the fourth century in China. Smallpox reached Japan in the sixth century, having been introduced by merchants and Buddhist missionaries from the Korean kingdom of Paekche. Once introduced, it recurred in waves. Increased trade across the Sea of Japan and the Korean Straight resulted in more frequent outbreaks.
In 736, a group of Japanese emissaries led by Abe no Ason Tsugumaro passed through the smallpox riddled region on their way to Korea. Abe no Ason would ultimately contract smallpox and die when the group reached Tsushima.
Forced to turn back, the group returned to the capital with smallpox, helping spread the disease to eastern Japan and Nara.
By 737, smallpox had spread across Japan and killed a third of the population. The death toll is calculated based on records of loan defaults for rice purchases, assumed to be tied to the borrower’s death, and the estimated population at the time. It is considered a conservative estimate.
The Black Death
Miniature by Pierart dou Tielt illustrating the Tractatus quartus bu Gilles li Muisit (Tournai, c. 1353). The people of Tournai bury victims of the Black Death. (Public Domain via Wikimedia Commons)
In the mid–14th century, large Italian cities managed an expansive trading network. With a growing population of around 12.5 million, large quantities of grain and flour were imported, with large trade networks established across Europe.
That trading network became a breeding ground for squirrels and black rats, which carry rat fleas, thought to be the main transmitter of bubonic plague to humans. Specifically, merchant ships sailing from the Black Sea into Italy are thought to have been the source of the bubonic plague outbreak in 1348. In Venice, ships traveling from infected ports would be required to wait 40 days before landing, to prevent the disease from spreading. Today, this practice is known as quarantine, from the Italian quaranta giorni, meaning 40 days.
Other recent theories have posited that human body lice are a more likely transmitter of bubonic plague during the Black Death. Regardless of the vectors of spread, between 1347 and 1351, it is estimated that more than 25 million people died. Worldwide, plague has killed more than 200 million people throughout history.
The Black Death marks the beginning of the second plague pandemic. The plague eventually became endemic and recurred regularly, but the second plague pandemic did not end until the late 18th-century. Outbreaks of plague still occur today, but the disease is now treatable with antibiotics.
1520 Mexico Smallpox Epidemic
Moctezuma, leader of the Aztec empire, and Spanish conquistador Hernán Cortés meet for the first time outside the city on the shores of Lake Texcoco. (Jay I. Kislak Collection, Library of Congress)
The Spanish conquest of 16th-century Mexico resulted in one of the most dramatic population collapses in human history. At the time of the Spanish arrival, there were 15 million to 30 million native inhabitants, but the native population would be decimated by the end of the century.
In 1520, Hernán Cortés and his conquistadores were forced to flee the Aztec capital of Tenochtitlan, today’s Mexico City, after the death of the Aztec emperor Moctezuma. They left their indigenous and African slaves behind, some already infected with smallpox.
In another example of “virgin soil” epidemic, the disease spread quickly, and some five to eight million people would die during the outbreak.
Cocoliztli epidemic of 1545–1548
'The Capture of Tenochtitlán', Cortés leads his Spanish armies on horseback across one of the causeways and lays siege to Tenochtitlán. He orders the complete destruction of the city. (Jay I. Kislak Collection, Library of Congress)
As the Spanish occupation spread throughout “New Spain,” an outbreak of a mysterious disease called cocoliztli (“pestilence”) would cause millions of deaths.
It is still unclear exactly which virus or disease was spreading but leading theories are that it was either salmonella or a viral hemorrhagic fever tied to drought and poor living conditions of the indigenous population under the Spanish.
Cocoliztli epidemic of 1576
After much of Tenochtitlán has been destroyed, Cuauhtémoc, the eleventh and last king of the Aztec empire, flees the city in a canoe and is captured by the Spanish. (Jay I. Kislak Collection, Library of Congress)
A second epidemic of Cocoliztli in 1576 would kill an additional two to two-and-a-half million people. As a result, the indigenous population continued to decline rapidly. In 1600, roughly 80 years after the arrival of the Spanish, the number of inhabitants in Mexico had plummeted to only two million.
1629–1631 Italian plague
The plague of the Philistines at Ashdod. Oil painting by Pieter van Halen, 1661. (Wellcome Collection)
Between 1629 and 1631, a series of bubonic plague outbreaks occurred in northern Italy and would become known as “The Great Plague of Milan”. This outbreak is still considered part of the second plague pandemic that began the 14th century.
The plague was thought to have been spread throughout Europe by French and German armies during the Thirty Years’ War, but infected Venetian soldiers brought the illness to Northern Italy.
Naples plague
L'Umana Fragilità | Human Frailty (Salvator Rosa, 1656, via The Fitzwilliam Museum, Cambridge)
In 1656, Salvator Rosa painted “Human Frailty,” wherein a baby signs a contract with Death, agreeing, “Conception is a sin, Birth is pain, Life is toil, Death a necessity.” The painting was created during the Naples plague, which ravaged the Kingdom of Naples and killed more than half of the population of the city of Naples.
1772–1773 Persian Plague
Physician talking to a female patient in a garden with servants preparing medicaments and potions. Persian lacquered binding board front cover of Avicenna's Canon of Medicine transcribed in Isfahan 1632. (Wellcome Collection)
Encouraged by war between the Romans and Persians, plague arrived in Persia (Iran) in 543 CE after passing from Italy through Syria, Palestine, and Iraq. It became an endemic disease with outbreaks usually confined to rural areas.
Beginning in Baghdad, the 1772–1773 Persian plague was much more virulent and spread quickly throughout most of Persia. While the British East India Company staff quarantined themselves away from the city, widespread quarantine practices weren’t introduced in the Gulf region until the Persian Plague of 1800, and disease would continue to spread widely.
The 1772 outbreak killed an estimated two million people across Persia.
Cholera outbreaks 1817–present
A Viennese woman who died of cholera, depicted when healthy and four hours before death. (Wellcome Collection)
Cholera outbreaks have occurred in waves since 1817. There have been seven major cholera outbreaks, the third and most deadly of which occurred between 1846 and 1860, beginning in Bengal, India, in 1839. British soldiers would spread the disease across Asia during the First China War between Britain and China in 1840 (also known as the Opium War).
Cholera would also spread along trade routes around the globe, penetrating into Arabia through pilgrims traveling to Mecca, crossing the United States, and reaching as far as Brazil through Portuguese trade. Estimates of a global death toll don’t exist, but some local and regional estimates do. For example, more than one million people are believed to have died of cholera in Russia alone during the third cholera major outbreak.
Original map made by John Snow in 1854. (Wikimedia Commons)
In 1854, English physician John Snow conducted the famous Broad Street outbreak study in London, showing that contaminated water helped to spread cholera. The subsequent removal of the pump brought the local outbreak to an end.
1889–1890 Flu Pandemic
The Dutch minister Bergansius and Hendrik Pieter Tindal visit an influenza hospital populated with representations of the countries of Europe; Bergansius points to the Dutch representative, attempting to persuade the apocalyptic Tindal that all is indeed well. Reproduction of a lithograph by J. Braakensiek, 1889. (Wellcome Collection)
Often referred to as “Russian influenza,” the first cases of the 1889 flu pandemic were reported out of Turkestan.
1918 Flu pandemic
Soldiers sick with Spanish flu at a hospital ward, Camp Funston, Fort Riley, Kansas
Known as “The Great Influenza Pandemic,” the first recorded cases of the 1918 influenza pandemic occurred at Fort Riley, Kansas. At the time, the United States was preparing to send thousands of soldiers to fight in World War I. The movements of troops between bases and close quarters helped the first wave of the disease to spread quickly and broadly across the United States.
Interestingly, despite originating in the US, the outbreak came to be known as the “Spanish flu” because, during the war, Spain was a neutral country whose newspapers covered the pandemic from the start. Other countries censored news of the flu to keep morale high—but Spanish news sources kept reporting on the flu, leading many to believe that’s where it originated.
Birds are natural reservoirs of influenza, and it can also survive in pigs—meaning that death rates for influenza can reach incredibly high levels because it doesn’t require humans to survive. Between 1918 and 1920, the virus is estimated to have caused between 40 million and 50 million deaths, more than the total deaths in World War I.
1918–1922 Russia typhus epidemic
Translated into English: The Red Army has crushed the White Guard parasites- Yudenich, Denikin, and Kolchak. Comrades! Fight now against infection! Annihilate the Typhus-bearing louse! (Published by Boni and Liveright, NY, 1921, Public domain, via Wikimedia Commons)
Typhus thrives in unsanitary conditions, and multiple wars allowed the disease to flourish in Russia in the early 20th century. Fueled by the Bolshevik Revolution in 1917, World War I, the Russian Civil War, and the Great Influenza Pandemic of 1918, there was ample opportunity for typhus to spread.
Typhus declined during peacetime, but another outbreak occurred after 1931 during Stalin’s introduction of the collectivization and gulag prison systems. Fear of typhus spread through Eastern Europe, and hatred was channeled towards those perceived as carriers of lice—refugees and Jewish peoples. Over time, the fear of lice merged with anti-Semitism, and Jews began to be seen as transmitters of parasites. The notion of “epidemic control” would be used as propaganda in Nazi Germany.
1957–1958 Influenza Pandemic
168 sick patients with the flu in Sweden, 1957. (Public domain, Wikimedia Commons)
Aided by air, sea, and rail transport, a new virus emerged from China in the winter of 1957 that would be referred to as the “Asian flu.”
At the time, it was unclear if the virus was the same as the 1918 influenza virus, but it would later be revealed that it was an H2N2 virus, rather than H1N1.
An estimated one to four million deaths would occur worldwide. In the US, 116,000 Americans would die, but it is thought that the number would have been much higher if not for the emergence of a flu vaccine that was provided to 30 million Americans.
1968 Influenza pandemic
Hospital corpsmen aboard the aircraft carrier USS George Washington carry a box of influenza vaccine aboard the nuclear-powered aircraft carrier USS George Washington. The vaccine is administered to all U.S. military personnel annually. (U.S. Navy photo by Mass Communication Specialist 2nd Class William Pittman, Public domain, via Wikimedia Commons)
The third influenza pandemic of the twentieth century began in Hong Kong in 1968. Known as the “Hong Kong flu,” the H3N2 influenza was less deadly than the previous Asian flu but highly contagious.
During the pandemic, an estimated 160 million people would travel by commercial airliners, increasing the speed of the spread.
Between 1968 and 1970, the pandemic caused by the H3N2 virus would kill one million people worldwide. A vaccine was developed and manufactured in 1968, but the virus had already peaked in many countries. As demand dropped, the vaccine was phased out of production in 1969. The pandemic, however, never ended—the pandemic caused by the H3N2 influenza virus continues today and is considered a seasonal influenza. (Get your flu shot.)
HIV/AIDS Pandemic
In 1988 the AIDS Coalition to Unleash Power (ACT-UP) organized a demonstration at FDA headquarters in Rockville, Maryland, to protest for greater access to investigational drugs to help treat AIDS patients. (Wikimedia Commons)
In early June 1981, the CDC published an article that described lung infections and suppressed immune systems in five gay men in Los Angeles. By the time the report was published, two of the five gay men were dead, and the others would die shortly thereafter. This was the first clinical article that described what would eventually be known as the HIV/AIDS epidemic.
Despite the progress, HIV/AIDS remains an ongoing pandemic. Across sub-Saharan Africa, in particular, death rates are still very high. In South Africa, Mozambique, and Botswana, HIV/AIDS is the leading cause of death.
COVID-19 Pandemic
COVID-19 testing in Madagascar, April 2020. (World Bank / Henitsoa Rafalia, CC BY-NC-ND 2.0)
In December of 2019, patients in Wuhan, China, began to exhibit pneumonia-like symptoms.
The general consensus is that the coronavirus known as SARS-CoV-2 spilled over from animals to humans, likely late in 2019. As yet, however, it is unclear whether the spillover occurred naturally or was the result of an accident in a laboratory studying coronaviruses.