CHAPTER 1 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.

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 Yersiniapestis, 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 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.

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

The initial symptoms of all forms of plague are not all that different from other diseases: These include high fever, violent headaches, and body stiffness, chills, or pains.

The bubo is considered by most medical experts—whether medieval or modern—to be the defining symptom for a conclusive diagnosis of bubonic plague, even when the case is so mild that it can barely be distinguished from other diseases.¹⁰ It is also the symptom that has allowed historians to make a positive identification of the first plague pandemic in history, owing to the de­scription by Procopius of Caesarea and John of Ephesus of the swelling that occurred in the “boubon,” the Greek word for groin, that accompanied the dis­ease’s appearance in Constantinople in 542 C.E.¹¹ In both modern and medieval cases, it has been noted that the bubo getting larger in size (approaching the dimensions of a walnut) is actually a good sign for a prognosis of recovery, even as it remains tender or painful to the touch.¹² After about a week of living with these symptoms, recovery is marked by spontaneous suppuration, or bursting open, of the bubo, releasing its pus;¹³ in the Middle Ages, the maturing or “rip­ening” of the boil was typically aided by a poultice or specially prepared plaster, cutting or scarification, cupping (applying a heated glass vessel to the area to create a vacuum suction), or cautery, either using inflammatory compounds or the more direct heat from a red-hot branding iron.

In the case of pneumonic plague, the characteristic symptom is the coughing up of bloody sputum, accompanied by rapid and painful breathing, although this can also occur in pneumonia, tuberculosis, and influenza. What seems to ultimately confirm the presence of plague is that in the pneumonic form it is 100 percent fatal and death ensues quite quickly, usually within two days. Unless they die suddenly from heart failure, pneumonic plague patients can be cursed with a horrible death, gasping for hours from “air hunger.”¹⁴

By contrast, septicemic plague has almost no distinguishing symptoms be­yond those characterizing the general onset of the disease, since it usually kills the patient too quickly—sometimes in twenty-four hours or less—to allow more marked outward signs such as the bubo to manifest themselves. However, for those who do live a little longer, before they invariably die, some very odd symp­toms can emerge, such as spontaneous bleeding from the nose and eyes, blood present in the urine and stool, and subcutaneous bleeding all over the body re­sulting in dark, purplish spots, called in medical parlance “petechiae” or “dis­seminated intravascular coagulation” (DIC).¹⁵ Tull still bears the purpuric spots on his skin from his bout with septicemic plague to this day. Interestingly enough, these same symptoms of petechiae or DIC also seem to have been noted by medieval observers of the plague.

As noted earlier, some disease epidemics that are called plagues were not true plague, as is the case of the “Plague of Athens” of 430—426 B.C.E., or the “An­tonine Plague” that struck the Roman Empire in 164—180 C.E.; both these ills were probably smallpox (to be discussed in chapter 2). Yet, plague was probably present in endemic form in the Mediterranean and the Near East in ancient times, even if it never seems to have broken out beyond localized epidemics.

In terms of the historical occurrence of the disease, plague is therefore re­served for one of three pandemics: the First Pandemic, sometimes also known as the “Plague of Justinian,” that struck the Mediterranean world between 541 and 750 C.E.; the Second Pandemic, more commonly referred to as the “Black Death,” that struck Europe and the Middle East beginning in 1347—1348 and persisted periodically right down to the eighteenth and nineteenth centuries; and the Third Pandemic, which struck Asia at the turn of the twentieth century, beginning with Hong Kong in 1894 and Bombay, India, in 1896, and that lasted down to the 1940s in India and Senegal, the 1950s in Thailand, and the 1960s in Vietnam. Indeed, the presence of plague to this day in the western United States stems from this last pandemic of the disease, when it first arrived in San Francisco in 1900. Each of these pandemics will now be discussed in turn.

A theme running through all three pandemics is that plague inspired some dramatic responses among the populations affected that had enduring conse­quences for cultural identity and survival. Not all of these responses, perhaps, are unique to plague, but they are usually associated with the disease because of both its unique nature and how it was perceived. As we have already noted, plague is a particularly deadly disease, killing in all of its forms an average of 70 to 80 percent of its victims, as well as striking with a very high morbidity, or incidence among the population at large, even if not all of them succumb to its mortality.

The First Pandemic of plague is important above all for setting the pattern of various societal responses to the disease, which were to recur during the Second and even Third Pandemics centuries later. Otherwise, its historical impact, both relative to the other pandemics and in the contemporary context of the early Middle Ages when it occurred, is still very much open to debate. Perhaps the most neglected of the three pandemics, the First Pandemic is only now starting to get some of the scholarly attention that it deserves.¹⁸

The First Pandemic seems to have originated in Upper Egypt, arrived at the eastern end of the Nile delta during the summer of 541, and spread eastward from there into the hinterland of southern Palestine.¹⁹ Alexandria was struck in the autumn of that year, followed by Jerusalem at the beginning of 542. By the following spring, the plague had come to Constantinople, the capital of the Byzantine Empire, from where it probably spread to Asia Minor, northern Pal­estine, Syria, and Persia. The plague persisted in the capital until August and then by the end of the year had reached North Africa and possibly Sicily and Spain. In 543 the disease spread to Italy, the Balkans, Spain, and France, and it reached Ireland in 544 but does not seem to have been known in England until a century later. There is further speculation that it may have struck Scandinavia and Poland at some point, but this is based entirely on interpreting the evidence of mass grave sites. After this first outbreak, plague seems to have returned to various parts of primarily the Mediterranean region in recurring waves, striking, with few exceptions, almost once a decade throughout the second half of the sixth, the whole of the seventh, and the first half of the eighth centuries. The last outbreak apparently encompassed Syria, Mesopotamia, Sicily, Rome, and Con­stantinople between 744 and 750.²⁰

Obviously, it was the first outbreak of 541—544 that became the most famous disease incident of this pandemic and has had the most historical impact. This is partly due to the attention it received from the Byzantine court historian, Pro­copius of Caesarea. But it is often overlooked that other sixth-century writers also recorded the pandemic, the most important of which was John of Ephesus, a churchman who witnessed the plague firsthand in his travels to Alexandria, Palestine, Mesopotamia, and Syria. Procopius, for his part, gives us an invaluable perspective from the capital, Constantinople, where he remained throughout the course of the epidemic. Based on the descriptions of these authors and others, there is little disputing that the disease that struck in 541—542 featured bubonic plague: both Procopius and John of Ephesus mention the bubones, or swellings in the groin, that became a signature symptom of the pandemic.²¹ A third eye­witness, Evagrius Scholasticus, adds the authority of his own personal experience to this identification, for he says that he himself came down with buboes during this first outbreak when he was a boy and later watched his wife, children, and several other members of his family and servants succumb to the same symptoms in later recurrences of the disease.²² For sources in Syriac and Arabic, special terms evolved that denoted the bubonic swellings and that were used to specifi­cally distinguish plague from more general references to “mortality” or “pesti­lence.”²³ Elsewhere, the occurrence of this symptom in the historical record is practically our only sure record of the disease: For example, Bede's mention that St. Cuthbert received a “tumor” on his thigh is our first evidence that plague struck England in 664.²⁴

How did Byzantine society and culture react to the First Pandemic? As would be expected, attributions of the plague to the marvelous and the divine figure large in contemporary accounts. Procopius reports visions “of supernatural be­ings in human guise” and dream portents accompanying the advent of the plague in Constantinople.²⁵ This is very reminiscent of the cult of Asclepius from an­cient Greece, and it should be no surprise that similar responses make their reap­pearance in a society imbued with Greek culture. “Terrifying phantoms” or specters were likewise cited by John of Ephesus as heralding the arrival of plague in southern Palestine, in the form of “headless black people” appearing on the sea off the coast in shining copper boats, a testament, perhaps, to the importance of maritime trade in spreading the disease. Otherwise, John of Ephesus employs a common rhetorical trope toward the beginning of his account in an attempt to convey the stupefying scale of the catastrophe: even if words could be found to describe it, a task that the author claims to find almost excessively daunting, who would be left alive to read them when the world is about to end, a sentiment summed up by the memorable phrase “for whom does the writer write?” These are the kinds of literary flourishes we encounter again during the Second Pan­demic, or Black Death. John's only answer to his own question is that perhaps future generations will learn from his contemporaries' punishment for their transgressions and so avoid their fate, a supremely ironic observation in light of the even more catastrophic Black Death some six centuries later.²⁶

John's theme of the plague being a punishment for people's sins is, of course, greatly amplified by his ample quotations from the Old Testament, which pro­vides numerous examples of how disasters such as the plague were just instru­ments of God's wrath.²⁷ But one must remember that, at this same time, the concept of original sin was being promulgated and developed by the Christian Church, largely through its leading thinkers such as St. Augustine (354-430 C.E.). Deriving its theology ultimately from the New Testament rather than the Old, original sin imposed an individual need for repentance upon the believer as the descendant of Adam, as opposed to the collective sense of guilt of an entire people when punished by Yahweh. It is striking, for example, how the plague apparently persuaded people to amend their lives, especially when they feared an immediate death, even though they would backslide once again as soon as the threat had passed. Here, Procopius is reporting a response that is almost the exact opposite of what had been chronicled by Thucydides.²⁸ Both authors concur, however, that many people who could have been saved from the disease instead died from sheer neglect, although Procopius excuses this un-Christian response with the exhausting effort that was required to attend plague patients.²⁹ John of Ephesus, on the other hand, tells a couple of stories of how people who sought to profit from the plague by seizing valuables of the dead were then immediately struck down as punishment for their greed.³⁰

Perhaps the most distinct impression of all that was made by the plague upon its chroniclers is the disposal of the ever-mounting corpses of its victims. The daunting and distressing prospect of what to do with all the dead had already been briefly noted by Thucydides, who reports that Athenian citizens resorted to mass cremation.³¹ Since this method of disposal was proscribed to Christian authorities, the challenge was what to physically do with perhaps thousands of bodies dying each day. It seems this was the most important and urgent brief for the imperial government during the crisis, dictated by both Christian duty and medical necessity, and both Procopius and John of Ephesus report that Justinian’s court responded with impressive alacrity and efficiency, something that is not always evident even in a modern, developed society of today.³² Mass burial pits were dug or improvised in existing buildings on Galata across the Bosphorous straits from the city, and corpse-bearers were drafted from among the soldiery, bribed with money from the imperial treasury, or simply forthcoming out of a sense of charity.³³ A memorable detail, supplied by John of Ephesus, tells of how gravediggers piled up and pressed down layers of bodies “as a man might heap up hay in a stack” or trod on them with their feet “like spoiled grapes,” while the trampled bodies sank and were immersed in the pus of five- to ten-day-old rot­ting corpses below.³⁴ This is just one of any number of John’s anecdotes that stick in the mind: litters bearing dead bodies bumping into each other on their way down to the docks; pus and viscera bursting out of rotting, bloated bodies and flowing down to the sea; noble families abandoned by their servants, including even the royal household, now reduced to a miserable handful huddled together in an empty palace; a house full of twenty forgotten victims whose bodies were so decayed worms were crawling through them; and infants still suckling from the breasts of their mothers even though they had died.³⁵ One can’t help but wonder if at least some of these searing images were directly inspired by what the author himself had witnessed.

The sheer enormity of the mortality—which meant that all the usual rites of Christian burial had to be set aside and the dead treated like beasts—is what seems to have shocked observers the most. Allied to this was John of Ephesus’ observation that people of all ranks, ages, and conditions were jumbled together into a degrading, meaningless muddle by the “wine press” of mass burial.³⁶ This is a theme that will crop up later during the Black Death and perhaps inspire the Dance of Death, one of the most powerful and popular artistic genres in the later Middle Ages. The fear of dying a nameless death was such that people took to going out with identification tags hung on their arms or necks.³⁷ The business of making wills and providing for inheritance was thrown into chaos, and both chroniclers report that all traffic and commerce came to a complete halt in the capital, which was mirrored in the countryside with domestic animals wandering about wild in the pastures and stands of grain ripening unharvested in the fields.³⁸ Aside from performing autopsies to investigate the source of bubonic swellings, physicians were alleged to be markedly ineffective in prognosis and treatment of the disease.³⁹

What is strikingly absent from contemporary descriptions is any role or pres­ence of the Church during the crisis; instead, people resorted to their own prayers or superstitions in an attempt to ward off the plague, such as hurling pitchers from their windows, which John of Ephesus claims was started by some mad “foolish women” inspired by demons. Indeed, monks and priests were ap­parently viewed as messengers of death and shunned with personal invocations of protection whenever they were encountered in the street.⁴⁰ There is even evi­dence of Christian backsliding in the face of the disaster, which is perhaps not unsurprising at this early stage of Christianity. In the border regions of Palestine, inhabitants began worshipping a bronze pagan idol, while even a good Christian like Evagrius might wonder how God could take away his whole family and yet leave the children of his pagan neighbors untouched.⁴¹ Pagans and homosexuals seem to be the only candidates for scapegoats during the crisis, even though measures were taken against them only after the danger had passed.⁴² While guilt could certainly be collective as an explanation for why God allowed plague to happen, authorities also made it clear that the extraordinary sin of certain groups provoked divine displeasure and therefore were in urgent need of correction.⁴³ This provided an important precedent that would help justify later pogroms, such as against the Jews during the Black Death.

It is probably fair to say that the First Pandemic of plague helped prevent the renovatio imperii, or “restoration of the empire,” that had been the life's ambition of the Byzantine emperor Justinian (527—565).⁴⁴ By 554, Justinian had com­pleted the reconquest of North Africa, Italy, and part of Spain, thus re-creating in large part the Mediterranean sphere of influence that had once been the glory of ancient Rome. The empire's failure to hang on to these conquests as the sixth century came to a close has been attributed to a number of other factors besides the plague.⁴⁵ But the massive mortality occasioned by the First Pandemic un­doubtedly played its part, largely by sapping the empire of the manpower it needed to defend its newly won territory. This was particularly true as the plague kept striking again and again after its first arrival on the scene in 541—542: plague's returns to Constantinople in 558 and 573—574, for example, were espe­cially ill timed due to incursions by a new enemy, the Avars, in the Balkans.⁴⁶ Moreover, the plague seems to have engendered a sense of weariness, and perhaps even guilt, over what otherwise should have been much celebrated accomplish­ments of the reign. In his Secret History, for example, Procopius confesses what he really thought of his emperor, whom he blamed for the death of no less than a trillion people. Most of these lives, we are informed, were lost in Justinian's unending series of wars, for which the emperor was directly responsible. How­ever, Procopius also believed that Justinian was, quite literally, a “demon in hu­man form,” whose very presence goaded God to allow natural catastrophes to occur, one of which was, of course, the plague of 542.⁴⁷ Perhaps no writer in history has been so abashed of his civilization's success.

Before we take our leave of the First Pandemic, we should note some other, later outbreaks of the disease and responses to them that were to have important implications for the Second Pandemic of the late Middle Ages. In 590, an out­break of bubonic plague struck Rome that, according to the chronicler Gregory of Tours, inspired the new pope, Gregory the Great, to preach a sermon calling for a procession of all the churchmen and inhabitants of the city. Like John of Ephesus, Pope Gregory amply quotes from the Old Testament to show how plague is an expression of God's anger in retribution for people's wickedness and sin; the difference, of course, is that Gregory now holds out the promise of re­prieve from God's punishment if the faithful but show their repentance. Despite the fact that eighty people fell dead in their midst, the procession continued.⁴⁸ Later legend supplied by Jacob of Voragine in the thirteenth century credited the procession with ending the plague when Gregory had a vision of an angel atop the Tomb of Hadrian sheathing his sword, indicating that the divine displeasure had finally been appeased. (By the ninth century, the tomb had been renamed the Castel Sant'Angelo to commemorate the event.) Yet, even this later medieval fiction had its Old Testament prototype, namely, the story told in the first book of Chronicles of how King David persuaded God to spare Jerusalem from a pestilence that had already killed seventy thousand Israelites.⁴⁹ Thus was estab­lished a precedent for prayers and processions, including perhaps the Flagellant movement, that were to play such a central role in how medieval society re­sponded to the Black Death.

By the seventh century, sermon cycles were being compiled to be recited on a regular basis whenever plague struck a region as part of the Church's now stan­dard response to urge its flock to repent in the face of God's wrathful chastise­ment; this at least is the overarching theme of four homilies composed at this time in Toledo, Spain, which, as expected, are replete with quotations from the Old Testament.⁵⁰ Yet, one sermon, the third in the series, adopts a strikingly dif­ferent tone by employing the carrot rather than the stick (although even the sermons that dwell on God's anger and chastisement hold out the hope of for­giveness and abatement of the plague if hearers will only repent). In a remarkable passage, one that seems to be inspired by the New Testament, in particular the letters of St. Paul, the preacher now dangles the promise of immortality during the Christian afterlife or resurrection in order to help his listeners conquer their fear of imminent death from the “groin disease”:

But what should we say? You who take fright at this blow (not because you fear the uncertainty of slavery, but because you fear death, that is, you show yourselves to be terrified), oh that you would be able to change life into something better, and not only that you could not be frightened by approaching death, but rather that you would desire to come to death. When we die, we are carried by death to immortal­ity. Eternal life cannot approach unless one passes away from here. Death is not an end, but a transition from this temporary life to eternal life. Who would not hurry to go to better things? Who would not long to be changed more quickly and re­formed into the likeness of Christ and the dignity of celestial grace? Who would not long to cross over to rest, and see the face of his king, whom he had honored in life, in glory? And if Christ our king now summons us to see him, why do we not em­brace death, through which we are carried to the eternal shrine? For unless we have made the passage through death, we cannot see the face of Christ our king.⁵¹

A very similar kind of response was developed concurrently in the Muslim world, as we will shortly see.

The last major outbreak to mention is the first to occur in the Islamic tradi­tion, the so-called Plague of ‘Amwas (named after the town in Palestine where Islamic troops first contracted the disease), which struck Syria and Mesopotamia in 638—639.⁵² This was an epidemic of bubonic plague that hit hardest in Syria and Palestine, including the capital, Damascus, beginning in the spring of 638 and not burning itself out until the autumn of 639. By taking out a whole gen­eration of Muslim leaders, the plague seems to have paved the way for the rise of Mu‘awiya, the founder of the Umayyad dynasty of caliphs (661—680). In 640, after the death of several Companions of the Prophet, which included his own brother, Mu'awiya was made governor of Syria, a position from which he was able to claim the caliphate after the assassinations of Uthman (644—655) and Ali (656—661). By extension, then, the plague also had a hand in the eventual splin­tering of Islam between the Shi‘ites (followers of Ali) and the Sunnis, who fol­lowed Mu‘awiya.

But for our purposes, the most important outcome of the Plague of ‘Amwas was the germination of the Muslim tradition that flight to or from a plague- infested area was prohibited to believers. This tradition only fully emerged later, by the eighth century; all that can be known for certain from a historical point of view is that Caliph Umar ibn al-Khattab (r. 634—644) attempted to make a journey from Arabia to Syria in c. 638 but turned back upon hearing of a “pes­tilence” there. Embellishments over the course of the next century and more added much drama to this story: how Umar, upon reaching the way station of Sargh on the border between Arabia and Syria, was met by the commander of his forces in Syria, Abu ‘Ubayda, who warned him that plague was raging in the region; how a debate then ensued among the caliph's advisers about what to do, some urging him to keep going and not turn back and others urging him to not expose himself and other leaders, including the Companions of the Prophet, to the plague; how after Umar decided upon retreat ‘Ubayda (who was to die from the plague in Syria) taunted him with the words “fleeing from the decree of God?”; how Umar then employed the parable of grazing camels on a lush slope rather than the opposite, barren slope to explain how they were “fleeing from the decree of God to the decree of God”; and how the debate was ended when one of the Companions belatedly arrived on the scene to quote Muhammad’s prec­edent, “If you hear of it [the plague] in a land, do not approach it; but if it breaks out in a land and you are already there, then do not leave in flight from it.” On this basis, Umar finally turned back to Medina. On historical grounds, the “Umar at Sargh” story has an air of inconsistency about it: why would ‘Ubayda, for example, both warn Umar against the plague and rebuke him for trying to avoid it? But in terms of the Prophetic tradition of Islam, it both satisfied a recur­ring theme in the Qur’an that resists any flight from adversity and deferred to a practical need to avoid unnecessary risks to the lives of the faithful. It was also a way to quarantine Arabia, which as yet was untouched by the plague, and to redeem the reputation of one of Sunni Islam’s most revered leaders, who was otherwise known as a fearless campaigner against the Byzantine and Persian Empires that he conquered.⁵³ This issue, along with two other alleged tenets of Islam concerning the plague—that the disease was a mercy and martyrdom for believers and that there was no contagion of plague since it came directly from the will of God—were to assume a very important and highly contested role in the religious/legal/medical communities of the Islamic world when the Second Pandemic, or Black Death, struck in 1348—1349. But for now, it is unclear what guidance was available to believers about how to respond to plague; it should be noted that, throughout the Near East during the First Pandemic, settled popula­tions seem to have fled the disease in large numbers.⁵⁴

How did such concerns play out in the Christian West? We have already noted how a sort of martyrdom that promised a spiritual communion with Christ was proffered to the faithful who died of plague in a Toledo sermon from the seventh century. By and large, however, the Christian tradition seemed to emphasize punishment rather than reward in its religious interpretation of plague, in contrast to the Muslim approach.⁵⁵ Perhaps this has something to do with the influence of the Old Testament and the Hebrew legacy upon Christian­ity. But I also think it very much ties in with Augustine’s theology of original sin, which would naturally endorse a more flagellating attitude. It is significant that the second Toledo sermon urging repentance in the face of plague bases itself on and quotes generously from Augustine’s own sermon on the threatened destruc­tion of the city of Constantinople, which was narrowly averted by communal procession and prayer (De excidio urbis).⁵⁶

On the other hand, Christian tolerance for flight from the plague (which dur­ing the Black Death was arguably far more pronounced and universal than in Islam, whose greater emphasis was on one’s duty to stay and tend the sick) seems

to be traceable back to pagan Greek influences upon Christianity, specifically the Quaestiones et Responsiones (Questions and Answers) of Anastasius of Sinai, a Greek monk writing toward the end of the seventh century. In Question 114, Anastasius offers a compromise between the religious and rational responses on the issue of whether one can escape the plague by fleeing from it: If the plague comes from God's will, then flight is useless, an answer that accords quite well with Islamic beliefs, except for the interpretation that the disease is a form of divine punishment. But if the plague originates from corrupt air, then fleeing to a healthier location is efficacious, which obviously owes much to the Hippocratic corpus (which also will form the basis of the Arabic medical tradition). Since Anastasius was both a Greek and a Christian, he seems here to be trying to rec­oncile the two sides of his heritage, a struggle that was quite a common one for the apologists in the early days of Christianity.⁵⁷ Although flight was to become a perfectly acceptable response for Europeans, even if they were churchmen, by the time of the Black Death, this by no means precluded that plague ultimately came from God's design, a widely held notion even among late medieval doctors. As it did for Islam at this time, the plague therefore posed something of a conun­drum for Christians in terms of how to respond to it based on competing tradi­tions, which was not to be resolved until the Second Pandemic centuries later.

Yet another literary tradition emerged during the First Pandemic that likewise evinced ambivalent attitudes toward the flight response to plague, but this time primarily from a social, rather than religious, point of view. Paul the Deacon, in his eighth-century History of the Lombards, recalls how, during a plague in Italy in 565, even close family members abandoned each other, as allegedly “sons fled, leaving the corpses of their parents unburied; parents forgetful of their duty abandoned their children in raging fever.” This might seem to be a clear condem­nation of those who abrogated their social obligations in order to save their own skins, yet the moral of Paul's story is rather ambiguous, since he also tells us that even those who stayed behind out of “longstanding affection” to bury relatives were themselves unburied and unmourned. What is incontestable is that people believed plague was contagious and therefore were faced with a stark choice, to either run away or face death. This, at least, seems to have been the general con­sensus of the population according to Paul, for “common report had it that those who fled would avoid the plague,” with the result that “dwellings were left de­serted by their inhabitants, and the dogs only kept house.”⁵⁸

Paul was not the only one who observed the fragile social fabric in the face of plague; the East Syrian Orthodox monk John bar Penkaye alleged that, during a plague in North Mesopotamia in 686—687, “No brother had any pity on his brother, or father on his son; a mother's compassion for her children was cut off.” John certainly disapproved of this behavior, for he noted that, when Christians failed to bury their dead and simply fled, their behavior descended to the level of pagans (in this case the Persian Zoroastrians) or else of “dogs and wild ani­mals.” Further proof of their ungodliness was how they responded if reminded that “no one can escape from God, except by means of repentance and conver­sion to Him.” According to John, they replied with blasphemous rebukes such as, “Get out; we know very well that escape is much more profitable to us than supplication.” This indicates that the rational response noted by Anastasius of Sinai was alive and well among the population at large. If not pursued by the plague itself, such sinful refugees were “harvested” by looters or dogs and wild animals. A more practical consideration was that abandoned exposed corpses, strewn about like “manure on the earth,” then contaminated water sources such as springs and rivers, which would only help perpetuate the disease.⁵⁹ On both moral and medical grounds, John informs us, flight had its drawbacks, even if it seemed to be dictated by self-preservation. These issues will necessarily be raised again during the Second Pandemic.

Scholarly consensus is inclined to be cautious in assessing the long-term im­pact of the First Pandemic of plague. There seems to be a desire to attribute neither too much impact to the disease nor too little.⁶⁰ This is in contrast to the cataclysmic upheaval almost universally accorded to the Black Death of the late Middle Ages. Yet, the case has been made that the First Pandemic of plague did no less than usher in the Middle Ages by sweeping away classical civilizations in Byzantium and Persia, thus clearing the way for the rise of peoples formerly on the periphery of the empire, such as the northern “barbarians” of Europe or the nomadic tribesmen in Arabia, both of whom allegedly suffered far less from the plague's ravages.⁶¹ This thesis is easily refuted if one but remembers that the Ro­man Empire, at least in the West, declined and fell well before the plague first struck in 541, or that Muslim armies had to contend with plague, particularly in their conquest of Syria, no less than Byzantine or Persian ones. In fact, the Um­ayyad dynasty was to reach its greatest extent at the very time when its power base in Syria was heavily targeted by plague, buffeting it with depopulations, agricultural contraction, and urban and rural dislocations; curiously, however, the dynasty came to an end at the very moment when the First Pandemic also reached its demise.⁶² And it was not until the dawn of the ninth century, when a generation or more of Europeans had lived with no need to fear of plague, that the northern barbarian kingdoms under the leadership of Charlemagne were fi­nally able to achieve recognition as equals from rivals in Constantinople and Baghdad. If plague did indeed play a role in such momentous events as the rise and fall of empires or the emergence of Europe, then surely it was only in con­junction with other forces that crashed in on the late classical or early medieval world: the mass migrations of Germanic tribes, for instance, or the birth of a dynamic, new religion—Islam—that was to become the great rival of Christian­ity. Instead, I believe that the varied and intangible cultural responses to plague outlined above, both with respect to Christian and Muslim communities in Europe and the Middle East, comprised the most enduring legacy of the First Pandemic: as already indicated, they helped set the stage for what was to come during the Second Pandemic centuries later.

Six centuries, to be exact, were to pass before another major outbreak of plague was to arrive in Europe and the Middle East. Since trade had played an instrumental role in spreading the plague in the Mediterranean at the beginning of the First Pandemic, particularly so as Egypt was the grain basket of the empire, the steady decline of international commerce through to at least the eighth cen­tury was probably responsible for the disappearance of the disease. Much new evidence has come to light—including distribution of pottery shards, ship­wrecks, and even traces of ancient pollution trapped in ice cores or peat bogs (indicating the relative strength of the metal smelting industry)—that points to the contraction of the Mediterranean economy and its shipping traffic, both on the sea and inland along rivers, which would thereby impose a virtual quarantine on the increasingly isolated port cities, first in the West and then later in the East.⁶³ Over time, the process also probably snowballed due to the fact that plague and the economy were undoubtedly intertwined: the more population declined due to disease, so too inevitably did demand for goods from abroad.⁶⁴ Indeed, the repeated occurrences of plague about once a decade throughout the First Pandemic ironically contributed to the very circumstances of the plague's demise. For instance, we now know that it was the plague, and not the irruption of Islam, that caused so much upheaval to the urban environments and settled regions of the Near East.⁶⁵ Other factors aside from plague assuredly played their role in disrupting Mediterranean trade and commerce and thus breaking the chain of infection of the disease; in turn, other possibilities besides trade, such as unintentional quarantine as people fled or avoided the already declining popula­tion centers of the Mediterranean once they became infected and changes due to genetic mutation or contamination in the virulence of Yersinia pestis, may have contributed to the decline of plague.⁶⁶

Plague returned to the world in a Second Pandemic that is traditionally seen to have begun in the 1330s from an endemic center in Central Asia. Evidence for this includes the archaeological discovery of three Nestorian Christian head­stones from the region of Lake Issyk Kul in present-day Kyrgyzstan, which record ten victims as dying from “pestilence” in 1338—1339.⁶⁷ Meanwhile, our most informed contemporary source, the Muslim author Ibn al-Wardi, writing in 1348 from Aleppo in northern Syria, a hub of trade for routes further east, states that the plague “began in the land of darkness” fifteen years earlier and then spread eastward from there to China and India and westward to the land of the Uzbeks, Transoxiana, Persia, the land of the Khitai (perhaps Turkestan), and fi­nally, Crimea and the Byzantine Empire.⁶⁸ (According to the fourteenth-century Muslim traveler Ibn Battuta, the “land of darkness” was an unexplored region lying beyond the Volga Bulgar state in present-day Tartarstan.) Modern-day re­search has confirmed that the Central Asian steppes are an ancient reservoir of plague, containing perhaps the oldest strains of Yersinia pestis based on the ge­netic mapping of its DNA.⁶⁹

Some scholars, however, propose southern Russia as an alternative origin to the Second Pandemic in place of Central Asia, arguing that references to “pesti­lence” and “land of darkness” are too vague to indicate a specific disease or geographical location, that the overland trade route across Central Asia presented insurmountable obstacles and would have taken too long to spread the plague from its endemic center to the West, and, finally, that the Mongol Khanates of the Golden Horde, Persia, and Turkestan all converted to Islam by 1326, which ensured a disruption of trade to both China and Europe.⁷⁰ If so, then this would imply that the Second Pandemic, like the first, was confined to Europe and the Middle East. Yet, Mongol efforts to expel the Genoese trading presence at Tana and Caffa during the 1340s were actually motivated more by the ongoing com­mercial rivalry between Genoa and Venice, the latter allying itself with the Kip­chak Khanate of the Golden Horde, and were therefore not designed to elimi­nate all Christian merchants from Mongol trade, let alone Muslim merchants who served as al-Wardi's informants.⁷¹ And although the various references to disease outbreaks in the East may be too vague to positively identify them as plague, neither do they rule it out. In addition to the Nestorian headstones at Issyk Kul, native Chinese annals do record a major epidemic in Hopei province in 1331 and epidemics in other regions beginning in 1345—1346, while Battuta mentions a disease epidemic in Madurai in southern India in 1344, from which he himself suffered. Both the Mongols in China and the Delhi Sultanate in India were in trade contact with Central Asia at this time, and there is a catastrophic drop in China's population recorded at the end of the fourteenth century that needs to be explained. If the Black Death was indeed a worldwide pandemic, affecting both East and West, then a Central Asian origin, at the crossroads of trade, is by far the most logical choice. Moreover, since Chinese annals report a series of other natural disasters—including floods, famines, droughts, and earthquakes—that coincided with its epidemics during the 1330s, this provides a powerful ecological explanation for why plague at this time should have sud­denly erupted out of its endemic centers to become pandemic.⁷² The sudden advent of a wetter and more unpredictable climate—part of a “Little Ice Age” that began in the early fourteenth century—may have forced rodents carrying the plague out of their remote habitats and into closer contact with humans.⁷³ It is also likely that the bad weather created famine conditions—as it did in north­ern Europe between 1315 and 1322—that compelled natives to hunt and eat marmots in greater numbers and more indiscriminately.

Wherever the plague began, there seems little disputing that the disease's entry point into Europe came at the Crimea, along the north coast of the Black Sea in southern Russia. Muslim and Christian merchants traveling back from this re­gion, which served as the westernmost terminus of the Mongol trade routes, car­ried reports back to the chroniclers al-Wardi and Gabriele de Mussis of Piacenza that the plague was rampant here in 1346. The Muslim source claims to have counted eighty-five thousand dead in the Crimea in that year, while Mussis tells his famous story of how Genoese merchants besieged in their trading factory at Caffa by the Mongol forces of the Kipchak Khan, Janibeg, were given the plague in an early form of biological warfare when the Mongols decided to catapult their dead into the town once they began to be decimated by the disease.⁷⁴ In reality, it is far more likely that plague was communicated via rats making their own, unobtrusive siege of the town or else by means of fleas hitching a ride on animal furs, which was the most important export product of southern Russia. However it came about, it is significant that plague first appeared outside Central Asia in the Crimea, rather than, say, in Iraq (1349) or Yemen (1351). This argues strongly for an overland dissemination route rather than by sea from the Indian Ocean and up through the Persian Gulf or the Red Sea.

From the Crimea, plague next commenced its march through the Middle East and Europe. It invaded the Byzantine capital of Constantinople by the late spring or summer of 1347 and then reached Sicily and Alexandria in Egypt around the same time, by the autumn of that year. At the end of 1347, plague may also have established bridgeheads at other strategic places in the Mediter­ranean, including the island of Mallorca off the eastern coast of Spain, the port of Marseilles in southern France, and the trading cities of Genoa, Pisa, and Ven­ice in Italy. In 1348, plague spread along the coast of North Africa and north­ward from Egypt through Palestine and Syria, hitting Gaza, Ascalon, Acre, Jeru­salem, Beirut, Damascus, Aleppo, and Antioch. In Europe, the plague in that year spread through Italy, the Balkans, much of France, and Spain and invaded Austria, Switzerland, southern England, and perhaps Ireland, Norway, and Den­mark. By 1349 and 1350, plague completed its conquest of North Africa, Spain, France, Austria, Switzerland, England, Ireland, Denmark, and Norway, and in addition it had come to Iraq, Germany, Belgium, the Netherlands, Sweden, Wales, Scotland, Poland, Bohemia, Hungary, Romania, and the Baltic States of Estonia, Latvia, and Lithuania. It was not until 1351 to 1353 that plague seems to have spread throughout eastern Germany, Poland, and Russia north of the

Caucasus. Based on all the available sources, which now include more than just chronicle accounts, it seems that the only large areas bypassed by the plague were Iceland and Finland, perhaps due to their isolation and sparse inhabitation.⁷⁵

Before we go any further, we should say a word about the controversy over whether the Black Death of the late Middle Ages was actually another pan­demic of the disease known as plague. It is curious that no such debate exists for the First Pandemic, even though theoretically the same objections ought to apply, but perhaps this is a function of far less surviving material available to pore through and dissect.⁷⁶ Recent research, including the emerging field of biomolecular archaeology, is fast rendering this debate obsolete: a tired, stale old chestnut that, to my mind at least, has now been definitely settled in favor of identifying the Black Death as plague. Indeed, so convincing is the accumu­lating evidence in plague's corner that I would contend that those who still insist on holding out against it are simply being ornery or, at worst, hypo­critical, since by rights they ought to make the same case for contesting the identity of the First Pandemic but so far have utterly failed to do so.⁷⁷ Such revisionist histories of the Black Death also seem to find it easier, and perhaps more attention grabbing, to make a negative case against plague than a positive one for any other disease.⁷⁸ In fact, a very positive case can now be made for identifying the Black Death with plague, based on the recovery of Yersinia pestis DNA from human dental pulp found on centuries-old victims of plague. This was first achieved a decade ago when late medieval and Early Modern mass graves were excavated at Montpellier, France. Although challenged as an isolated and unreliable result, it has now been duplicated in London and Ger­many for victims from the First Pandemic of plague.⁷⁹ Provided that such positive identifications continue, biomolecular archaeology will thus soon de­finitively settle the matter.

One other bone of contention needs to be addressed here with regard to the medieval Black Death: its demographic impact. How many people in the Middle Ages were killed off by the disease? The numerical percentages are important, because they determine how much of an impact the Black Death may have had upon late medieval society. A nearly universal mantra among both past and pres­ent histories of the Black Death is that it killed off roughly a third of the popula­tion, on average, in its first outbreak in Europe and the Middle East between 1347 and 1350, with progressively lower mortalities rates thereafter when the plague returned throughout the second half of the fourteenth and throughout the fifteenth centuries. Such an assertion made it quite easy for past scholars of the plague to downplay even its initial impact, claiming that this was nothing out of the ordinary within the context of periodic Malthusian declines that are predestined to occur throughout history.⁸⁰

However, in recent years, a veritable tidal wave of data has been painstakingly extracted from various sources mainly in England, Spain, Italy, and France, all of which points to an average mortality of 50—60 percent during the first outbreak of the Black Death in 1347—1350. This figure can probably be applied to all of Europe and the Middle East, even where comparable records are not available, since what records we do have give a fair enough representation of different pat­terns of human settlement (i.e., both urban and rural populations), as well as class members of society (i.e., peasantry, priests, professionals, etc.). This is an astonishingly high number that is undoubtedly the highest mortality percentage ever recorded for a single disease outbreak, and best estimates are that it repre­sents a loss of as much as fifty million people throughout Europe in just a few years.⁸¹ No such loss can be sustained without very dramatic social, economic, and psychological impacts upon a society.

As in the First Pandemic, plague was to return to Europe about once a decade throughout the later Middle Ages, striking on average every eleven years in fif­teen recorded outbreaks between 1360—1361 and c. 1500. (This almost exactly matches the average of 11.6 years for the eighteen outbreaks recorded between 541 and 750 C.E.)⁸² Although the virulence of these recurrences of plague seems to have gradually declined, based on testamentary and other evidence, the cumu­lative impact of even low mortalities could take their toll. Thereafter, plague re­curred slightly less frequently during the Early Modern period, averaging an outbreak every 13.4 years between 1535 and 1683. However, plague continued to have the reputation of being the most lethal disease: Indeed, one of the ways in which seventeenth-century Italian doctors distinguished plague from other fever-type diseases such as malaria or typhus was whether or not the epidemic carried off the majority of the town's population.⁸³ Spectacular eruptions of the disease continued to occur, such as the Plague of Naples in 1656 that killed half of the city's roughly three hundred thousand inhabitants, or the Great Plague of London of 1665 that carried off one hundred thousand victims, representing 20 percent of the city's population. By 1670, plague is thought to have virtually ceased in Western Europe, but it continued to strike in Eastern Europe and Rus­sia down through the eighteenth century. In the Balkans, North Africa, and Southwest Asia, plague was endemic up until the first half of the nineteenth century. The last major outbreak in Europe, in 1720 at Marseilles in southern France, came from a cargo ship originating in Syria.

The varied impact of plague's ravages upon late medieval society—medical, religious, social, and economic—will now be examined in a comparative way between Europe and the Middle East. First to be considered is the medical re­sponse to the Black Death. In terms of the first outbreak of 1348—1350, doctors in both Europe and the Middle East had a remarkably similar set of answers to the all-important questions of what caused the disease, how was it to be pre­vented, and how was it to be cured? These framed the structure of almost all medical treatises on the plague down to the end of the Middle Ages and beyond. Such consistency owes largely to the common inheritance that both Christian and Muslim cultures shared from the ancient world, namely, the Greek and Ro­man medical traditions of Hippocrates and Galen, as mediated by Arabic physi­cians of the early and high Middle Ages, especially Ibn Sina or Avicenna (980— 1037). This meant that both Christian and Islamic physicians explained the plague as caused by a miasma, or substantial corruption of the air, either from a higher source (i.e., the planets) or a lower one (swamps, rotting corpses, earth­quakes, etc.). Both subscribed to the six “nonnaturals” as a means of preven­tion—regulating intake of air, diet, exercise, sleep, repletion and evacuation, and “accidents of the soul,” or mental states—in order to avoid predisposing the body to the disease. And both prescribed surgical intervention and special medicines in their “cures” of plague. Although both acknowledged that the Second Pan­demic of plague presented an unprecedented and overwhelming challenge (both in terms of its virulence and its geographical extent) that was virtually unknown to ancient authors, this did not invalidate, in their minds, the age-old theoretical underpinnings of their profession. After all, plenty of explanations, such as the predisposition of an individual’s “complexion” to the disease, could be brought forward to explain failures of treatment. Indeed, the typical contemporary re­sponse to the plague was to do what their predecessors had done, only to do it more intensely and more urgently, such as by bleeding in greater amounts and as soon as possible, with little regard to the usual constraints and cautions sur­rounding the procedure. Likewise, theriacs, pestilential pills, and other medicinal compounds, whose recipes were handed down since ancient times, were now prescribed in greater variety and number. Rather than any real evolution in medical attitudes or approaches to plague over the course of the later Middle Ages and down into Early Modern times, it seems that whatever empirical ob­servation and experience doctors obtained of plague was used to actually rein­force the traditional assumptions, or “paradigm,” they had inherited from past authorities.⁸⁴ If ancient doctors had never had to face a disease like the Black Death, then this simply meant that they never had the chance to apply and test their medical expertise in the crucible of plague, as doctors were now doing. That a First Pandemic had equally challenged the medical profession was either un­known or conveniently forgotten.⁸⁵

In terms of other communal responses to the Black Death, three “religiolegal principles” are assumed to distinguish medieval Muslim communities in the Middle East and Spain as compared to those in the Christian West: these include that plague is a mercy and martyrdom for believers; that one should not flee from or enter into a plague-infected region; and that plague comes directly from God and through no other agency, such as person-to-person contagion.⁸⁶ In actual fact, the differences between the respective communities along these lines are much more nuanced than have been previously portrayed, as are the nature of the beliefs held within each community itself.⁸⁷

Contrary to popular perception, the Prophetic tradition of Islam was not universally hostile to the concept of contagion. Since Islam embraced, and in­deed passed down to the West, much of the intellectual heritage of ancient Greece and Rome, it should come as no surprise that Galen's theory of contagion as the “seeds of disease” passing from person to person in the form of a localized miasma should be taken up by doctors in the Muslim world during the ninth and tenth centuries, who applied it especially to leprosy and who interpreted it as no different from an infection that spread from a sick person to a healthy one. Pre-Islamic societies in Arabia also subscribed to contagion, expressed as the “stinging of the jinn' or demonic spirits, a concept that Muhammad according to the hadith is said to have explicitly endorsed, along with another tradition in which the Prophet allegedly commanded, “Flee from the leper as you would flee from a lion.” Contagion was also instinctively understood from the spread of mange disease among the Arabs' camel herds, even though the hadith has Mu­hammad counter with the reply “And who caused the mange in the first one?” as a way of drawing the ultimate chain of causation back to God. A contradictory attitude is likewise evinced to the jinn during the Plague of Amwas in the sev­enth century, when one of the Companions of the Prophet reportedly spread this belief among the rank and file of the Arab army in Syria, until he was sharply rebuked and contradicted by a more pious superior, who asserted that the plague was a “chastisement” (evidently not yet the “martyrdom” for believers of later tradition) sent down from God as he had done earlier to the Israelites. But by the fourteenth century, on the eve of the Black Death, even the “medicine of the Prophet,” which claimed to be rooted in the religious canons of Muhammad, accepted the Greek humoral theory of disease causation and listed contagion as one of the possible secondary causes of plague that was not incompatible with God as its ultimate source.⁸⁸

The famous plague treatises of the Moorish physicians and scholars, Ibn al- Khatib and Ibn Khatima, who wrote at the time of the first outbreak of the Black Death in 1349, were not therefore rationalist exceptions to the Islamic tradition just because they endorsed contagion with empirical arguments. Even though they took diametrically opposite views on the relationship that religion should have with medicine, both Khatib and Khatima cite concrete “proofs” for person- to-person transmission of the plague, such as through the infected breath or bodily vapors of the sick or through their personal belongings, including cloth­ing, furnishings, utensils, and even a single earring! But of course, this is not an accurate depiction of the epidemiological realities of bubonic plague, so one can question whether it is indeed a rational or empirical response to the disease at all (except for cases of pneumonic plague, which Khatima does seem to provide).⁸⁹ Furthermore, both Khatima and Khatib do attempt to demonstrate that their “empirical” observations of plague's contagion are not incompatible with the Prophetic tradition of Islam. This is far more pronounced in the case of Khatima, who devotes the last four chapters of his treatise solely to the Prophetic tradition itself (thus being concerned with religious rather than medical matters) in an ef­fort to reconcile and smooth over what seems like a jarring contradiction on the subject of contagion, especially as stated briefly under the heading of “infection” in an earlier chapter. While subscribing to a very orthodox position that God is the sole author of disease, Khatima also advances the idea that contagion is a secondary (but not independent) cause. He thus follows in the footsteps of a long tradition dating back to at least the ninth century, which included not only the adherents of Prophetic medicine but also certain commentators on the hadith who were concerned with maintaining its integrity in the face of the challenging conundrum posed by contagion. But even Khatib takes a (very brief and seem­ingly halfhearted) stab at trying to harmonize contagion with Islamic law, drawing on both selective quotations from the hadith that seemed to support his position and the principle of maslaha, or the privileging of what was for the good of the Muslim community over specific fatwas that might do it harm (such as not to flee the plague). In the end, however, Khatib prefers to abruptly end the discussion by stating simply that it “is not among the duties of medicine,” in contrast to the way his colleague, Khatima, extensively grapples with the issue.⁹⁰

The real innovation of Khatib, and the one that stood most in contrast to the writings of Khatima and that has made him such an attractive figure to modern skeptics of the Prophetic tradition in both the Middle East and the West, is his insistence on a separation of the two realms of religion and science (in this case, medicine) should the interests and agendas of the two intersect and conflict. Particularly important is his notion that, in a matter of science, that is, where the public health as threatened by the plague is concerned, empirical observation and proof should be privileged over religious authority. While this may not be entirely unprecedented, it is prescient in that it foreshadows one of the founding principles of the Scientific Revolution centuries later. It is also a very controver­sial position, one that would have raised eyebrows among contemporaries in both Islamic and Christian contexts. Toward the close of his short treatise, for example, Khatib states the following: “One principle that cannot be ignored is that if the senses and observation oppose a revealed indication, the latter needs to be interpreted, and the correct course in this case is to interpret it according to what a group of those who affirm contagion say.”⁹¹ This is not so different, after all, from what Galileo Galilei was saying in the seventeenth century, which resulted in his condemnation as a heretic before the Roman Inquisition in 1633. By contrast, Khatib’s trial, which ended with his death at the hands of a lynch mob in his prison at Fez in 1374, seems to have been primarily a politically motivated one relating to his time as vizier of Grenada during the 1350s and 1360s. However, one of the accusations at his trial, that Khatib followed “the doctrines of the classical philosophers in questions of faith,” may be quite rele­vant to his views on contagion. Although what exactly his offense was in this matter is not entirely clear, if it was seen that Khatib was privileging Greek ratio­nalism where it conflicted with faith, then this would be quite similar in prin­ciple to what he expressed in his plague treatise.⁹²

The difference between Muslim and Christian commentators on contagion was therefore not a straightforwardly simple one, in which one society or culture accepted the concept and the other did not, but rather one of degrees in terms of this acceptance. In this sense, Christian Europe was an unabashed subscriber to contagion, with little to no reservations, compared to the Islamic world. Out of the hundreds of plague treatises I have consulted from fourteenth- and fifteenth­century Europe, there are none that I know of that deny contagion, on religious or any other grounds. (This also applies to the two Hebrew treatises of Rabbi Isaac Ben Todros and Abraham Kashlari.) When European plague doctors specifically discuss contagion, they do so largely in a theoretical way that almost seems to take the concept for granted and that precludes disagreement or challenge. For exam­ple, the famous Perugian physician, Gentile da Foligno, explains contagion in his Long Consilium of 1348 as “poisonous vapors” that can pass “not only from man to man but also from region to region” by means of being breathed in or else absorbed through the pores of the body, which then generate a “poisonous mat­ter” in the region of the heart and lungs. Rather than cite his own observation or contemporary empirical evidence, Foligno quotes the unimpeachable source of Galen and his theory of the “seeds of pestilence” from De Differentiis Febrium (Concerning Different Types of Fevers), and he asserts, again on the authority of Galen, that anyone who stays in a neighborhood infected with plague and who converses with those “covered with sores” or “whose breath is putrid” will be sure to get the disease “just as if they were cast into an oven like bread dough.”⁹³ To justify plague contagion by sight (what the Muslims termed the “evil eye”), an anonymous practitioner from Montpellier in 1349 quoted at length from Euclid’s theory of optics, but he also referred to legendary tales of the basilisk and of the “venomous virgin,” both of whom could kill by look alone, that would nonethe­less be just as convincing to his readers since one could find them in respectable sources such as medieval bestiaries and the Secretum Secretorum (Book of the Se­cret of Secrets) attributed to Aristotle.⁹⁴ On occasion, Christian plague doctors do cite empirical evidence and observation in support of contagion, just like their Muslim colleagues: the author of an anonymous German treatise from the fif­teenth century testifies that he saw two boys touch a dead woman's bedding that had been thrown out into the street to dry in the sun, after which they both straightaway died of the disease.⁹⁵ This is exactly analogous to Khatima's witness­ing the deaths of people who used to traffic “in the clothes of the dead and their furnishings” at the old-clothes market in Almeria, Spain.⁹⁶

In contrast with the Christian West, the concept of contagion was a highly contested one in the Islamic world. While Khatima and Khatib vigorously de­fended contagion, other contemporary authorities explicitly denied it. Chief among these was the fourteenth-century Granadan jurist, Ibn Lubb, who re­jected contagion on a number of grounds, including theological objections (backed by a long line of commentators on the hadith) as well as claiming that it conflicted with the social and moral obligations of Muslims. He was joined by a number of other fourteenth-century authors from North Africa and al-An­dalus, including the famous Ibn Khaldun, who seemed to deny any role for secondary causes in the plague, and therefore of contagion. In the fifteenth cen­tury, the enormously influential plague treatise of the Egyptian scholar Ibn Hajar al-Asqalani apparently turned the tide of majority Muslim opinion against con­tagion, largely by refusing to rely solely on the Prophetic tradition to make his case. Hajar claimed that plague had to have a nonnatural (i.e., noncontagious) cause because in his own times he observed that some people, even those within the same household as a plague victim, did not contract the disease and because doctors still hadn't found a cure, which only God could ordain. (In response to both observations, most Christian physicians would probably have pointed to the individual complexions of patients that differentially predisposed them to disease and to the need to start a cure almost immediately, at most within twelve hours of the onset of symptoms, for it to be successful.) Hajar's preferred expla­nation was the jinn, for which, incredibly to modern readers, he likewise ad­vanced sure proofs in the form of testimony from no less a personage than the Egyptian sultan's private secretary, who related how he had overhead two invisi­ble demons arguing behind his back over whether to “pierce” him with the plague or not; in the end, they decided to strike out the eye of a horse instead. This is really not so different from the Montpellier physician's appeal to the basilisk and the venomous virgin in support of contagion by sight. Hajar thus provided a potent counterargument to those who would defend contagion, par­ticularly as it marshaled doctors' favorite weapon, empirical evidence and obser­vation, against them. His writings and opinions changed the whole terms of the debate over contagion in subsequent plague treatises written in North Africa down to the nineteenth century. By contrast, plague treatises in the Christian West showed remarkable consistency: their theoretical underpinnings were to remain essentially unchanged throughout Europe's late medieval and Early Mod­ern experience with the disease.

If there was debate or disagreement among Christian plague doctors, it was in terms of the role that God played in causing the disease, specifically as a pun­ishment for human wickedness or sin. In their Consultation penned for the king of France in October 1348, the Paris medical faculty included a formulaic nod from medicine to religion along the lines of “an epidemic always proceeds from the divine will” and that “God alone heals the sick,” although they also did not “neglect to mention” that their profession was sanctioned by God and that prayer did not preclude consulting doctors, which was a paraphrase of the “honor the physician” passage from one of the apocrypha, Ecclesiasticus 38:1—14, attributed to Jesus ben Sirach. Earlier that year, the Lerida physician Jacme d'Agramont declared that, “if the corruption and putrefaction of the air has come because of our sins, [then] the remedies of the medical art are of little value, for only He who binds can unbind.”⁹⁷ In 1448, the Apulian doctor Saladin Ferro de Esculo listed as his first cause of plague God's desire “to punish the sins of men,” which he would not elaborate on because it was incapable of doubt.⁹⁸ Yet, even these deferential doctors were making the point that God was only one of many pos­sible causes of plague; more usually, Christian commentators preferred to argue over whether the disease came from a higher natural cause (such as planetary conjunctions) or a more local one (such as the stench arising from swamps, rot­ting corpses, earthquakes, etc.).

However, a significant handful of Christian Europeans resisted the notion that God had anything at all to do with the disease. The German science writer (and priest), Konrad of Megenberg, in a treatise of c. 1350 on “whether the mortality of these years comes from divine vengeance on account of the iniqui­ties of men, or from a certain natural course [of events],” came down in favor of the latter conclusion on two grounds: first, if God “made this plague for the cor­rection of men” then he did so “to no purpose” (which is not to be admitted), because “experience teaches us that His people have in no way amended them­selves of any vice”; second, God in his vengeance “would have struck down all mortal sinners,” but again, experience shows this not to be true. He then goes on to make a positive case for his preferred, natural explanation of the plague, earth­quakes.⁹⁹ Around this same time, the Naples doctor Giovanni della Penna urged his colleagues to investigate “natural causes” for plague, “since [only] unskilled and ignorant physicians say that it proceeds from God or from the heavens.”¹⁰⁰ A century later, an anonymous Bohemian treatise of c. 1450 complained that patients often gave in to a sense of despair and lost hope during a plague because they believed “that it's God's vengeance or anger over them” and this belief en­gendered a fatal sense of guilt over their sins. This was one of six “contributory causes” of plague that defied the doctor's best efforts to help people avoid or cure the disease.¹⁰¹ All this skepticism about God's role in the plague finds no parallel in the medieval Islamic world.

Closely related to the issue of contagion was whether to flee or avoid persons and places infected with plague. On this question, Christianity and Islam emerged on opposite sides by the end of the Middle Ages even more clearly than in the case of contagion. From the very beginning, Islam seems to have decided firmly against sanctioning flight from a plague-infected region, dating back to at least the eighth-century rendition of the Plague of ‘Amwas during the First Pan­demic. As we have seen, this established a rule, said to have come from the mouth of the Prophet himself, that if a plague is “in a land, do not approach it; but if it breaks out in a land and you are already there, then do not leave in flight from it.” At the same time, in the Christian tradition, Anastasius of Sinai hedged on this issue, allowing for flight if the disease originated from corrupt air instead of directly from God's will. However, in one Muslim interpretation of the ‘Am­was incident from the twelfth century, that of the Moorish jurist Ibn Rushd al- Jadd (grandfather to the more famous Averroes), the Prophet's dictum against flight was to be interpreted not as a blanket prohibition but rather as “humane guidance and advice,” so that it was permissible (if not preferable) to enter or leave a plague-infected region so long as “one's intention is correct and one relies on God.”¹⁰² But this interpretation seems to have been a unique one that was not widely accepted in the Islamic world. It could be said that Khatib also advocated flight from the plague in his treatise of c. 1349, but this is by inference only (since he so strongly espouses the concept of contagion); nowhere does he actu­ally come out and say that people should flee. The examples he gives of those who successfully avoided the plague are those who quarantined themselves rather than availed of the option of flight: one Ibn Abu Madyan of the city of Sale, who walled himself up along with his whole family after hoarding enough food to live on, and the thousands incarcerated in the prisons of Seville who also miracu­lously survived.¹⁰³ Khatib's advocacy of flight was therefore rather ambiguous, even as he condemned those who would deny Muslims this course of action.

On the other hand, fourteenth-century Islamic Spain also witnessed a highly influential fatwa that was issued in no uncertain terms against any kind of seek­ing of refuge from the plague. This came from the quill of the jurist Lubb, who was a contemporary of Khatib and who like him was based in Grenada, Spain. In fact, it is quite likely that it was Lubb's two fatwas on the plague that Khatib had in mind when he famously wrote, “And amidst the horrible afflictions that the plague has imposed upon the people, God has afflicted the people with some learned religious scholars who issue fatwas, so that the quills with which the scholars wrote these fatwas were like swords upon which the Muslims died.”¹⁰⁴ Khatib then goes on to cite approvingly the example of “a group of pious people in North Africa” who nonetheless renounced their previous fatwas on the plague “in order to avoid being in the posion of declaring it permissible for people to engage in suicidal behavior.”¹⁰⁵ One can easily imagine that Lubb himself did not see things quite this way.

It was in his second fatwa that Lubb responded to an enquiry as to whether it was permissible for a Muslim to flee a plague epidemic once one saw it afflict­ing his religious brethren. Given that his first fatwa emphatically denied plague contagion, it should come as no surprise that Lubb also denied to Muslims any right to flee the plague under any circumstances, citing a series of precedents from the Prophetic tradition culminating with that of the Plague of ‘Amwas. As Lubb movingly recites, “A Muslim is a brother to a Muslim, he does not forsake or oppress him.” As he did in the first fatwa, Lubb did not just rely on religious arguments to make his case; he also appealed to the social and moral duty of a Muslim not to abandon a fellow believer when sick with the plague. To do oth­erwise would be to threaten the integrity of the whole fabric of the umma, or Islamic community.¹⁰⁶ Thus, in evident contrast to Khatib, who seems focused on saving individual lives, for Lubb the greater cruelty was to allow a Muslim to flee and forsake his obligations to others: one must never forget that one is part of a whole. This argument against flight as a “moral failing” was to persist in Muslim plague treatises down through the fifteenth century and beyond. The only exception comes in a fifteenth-century poem or maqama attributed to ‘Umar of Malaga, who urged the sultan of Granada to flee to Malaga to save his life during a plague in 1441, on the grounds that the Prophet's injunction not to flee was not an absolute decree, along the lines earlier laid out by Rushd.¹⁰⁷ But his was a lone voice in the wilderness.

On the Christian side, there was an equally strong tradition in favor of flee­ing the plague. It was nearly ubiquitous advice in European plague treatises to advise readers that, as soon as there was word that plague was coming to town, “to start early, go far, and return late,” a turn of phrase apparently derived ulti­mately from Galen.¹⁰⁸ Yet, some doctors also recognized that patients who were left unattended were more likely to succumb to the plague: the fifteenth-cen­tury German doctor John of Saxony listed “a lack of faithful servants to assist the sick man,” particularly in performing his “operations of nature,” as one of the contributory causes to why people died of the disease, and an anonymous Bohemian treatise of c. 1450 said basically the same thing. But if doctors were advising people to flee the plague because they believed it was contagious, then they really only had themselves to blame if sick patients were left unattended.

John of Saxony can hardly have been surprised, for example, when he observed that even “parents during this plague also fear to draw near to their children and other beloved relatives,” an observation that was echoed in many chronicles of the Black Death.¹⁰⁹ Moreover, the plague regulations passed by some Italian cities, such as Milan in 1374, actually penalized those who attended the sick by quarantining them from the rest of society for a period of days.¹¹⁰ In a sense, this paradoxical dilemma distantly reflects the early history of Christianity it­self, when Jesus' followers saw it as their duty to both succor the sick and the poor and flee from the world with all its dangers and temptations (as the desert fathers did in a very literal sense).

To square this circle, doctors did not so much advise people not to flee as provide preventative measures so family members and servants might safely stay and nurse the sick: precautions such as fumigation or ventilation of the air around the patient or keeping one's distance from the patient, all the while inhaling aro­matics, taking pills, and evacuating one's excess humors by means of bloodlet­ting—all intended to “fortify” the body against the plague. The dilemma doctors faced in terms of these competing agendas can be seen in the various consilia on the plague written by Foligno. We have already seen how in his Long Consilium written early in 1348 Foligno fully endorsed plague contagion on the basis of Galen, and on these grounds he advised that “it is of the highest importance that one flee from [bad] air” before the plague spread inexorably “from man to man, household to household, neighborhood to neighborhood, and city to city.”¹¹¹ But in a shorter Consilium written later that year, Foligno changed his tune, stating that it was important for the healthy to take preventative measures, “in order that those who attend the sick may be able to be by their side more securely [and] in order that those who become sick are not neglected beyond all inhumanity and abandoned in such a miserable way as hitherto and in a manner that is usually accorded to brute beasts.”¹¹² The anonymous physician from Montpellier who championed contagion by sight in a treatise of 1349 warned that attendants of plague patients were in especial danger, particularly if they look “at the sick man in his death throes.” But any visitor, whether he is “a doctor or priest or friend,” could easily remedy this situation by blindfolding the patient.¹¹³ (So much for the medieval bedside manner!) Over a century later, another anonymous treatise, dated to 1481, gave six special medicines to be taken by anyone having to stay with a sick person; even though it also advised fleeing the ill, this was to happen particularly when patients were in their last death throes, by which time it was understood that there was not much to be done for them anyway.

In addition to these medical misgivings, some Christian Europeans also had social and moral reservations against flight. Giovanni Boccaccio, for example, in his introduction to the Decameron that describes the impact of plague in his na­tive city of Florence, famously writes that, during the Black Death of 1348, “this scourge had implanted so great a terror in the hearts of men and women that brothers abandoned brothers, uncles their nephews, sisters their brothers, and in many cases wives deserted their husbands. But even worse, and almost incredi­ble, was the fact that fathers and mothers refused to nurse and assist their own children, as though they did not belong to them.”¹¹⁴ As we have seen, some such observation had already been made during the First Pandemic by Paul the Dea­con and John bar Penkaye. However, the plaint of abandonment received much wider circulation during the Black Death: it was repeated by no less than nine other Italian chroniclers; three writers from Avignon, including the surgeon Gui de Chauliac; and by two French poets, Simon of Corvino and Guillaume de Machaut. Either all these various authors were borrowing from Paul, or each other, or else at least some of them were recording genuine historical incidents, which seems more likely given that plague doctors were advising their clients to flee the plague.

It is even argued by one historian that Boccaccio’s entire introduction is de­signed as a “strong, moral critique” of doctors and their medical advice, which he saw as a threat to society’s obligations to have compassion and take care of the sick.¹¹⁵ At one point, Boccaccio writes,

Some people, pursuing what was possibly the safer alternative, callously main­tained that there was no better or more efficacious remedy against a plague than to run away from it. Swayed by this argument, and sparing no thought for anyone but themselves, large numbers of men and women abandoned their city, their homes, their relatives, their estates and their belongings, and headed for the coun­tryside, either in Florentine territory or, better still, abroad. It was as though they imagined that the wrath of God would not unleash this plague against men for their iniquities irrespective of where they happened to be, but would only be aroused against those who found themselves within the city walls; or possibly they assumed that the whole of the population would be exterminated and that the city’s last hour had come.¹¹⁶

This kind of behavior had real consequences and was in effect a self-fulfilling prophecy of doom for the city’s remaining inhabitants, since as a result of being abandoned “a great many people died who would perhaps have survived had they received some assistance.”¹¹⁷ All this is quite similar to what Lubb was say­ing in his fatwas on the plague in Islamic Spain.

At the same time, however, Boccaccio and others who seemed to disapprove of flight freely admitted that plague was contagious, which Boccaccio illustrated with his own eyewitness testimony of how two pigs fell down dead after mauling the rags of a pauper who had died of the disease. If plague could transfer itself not only from sick to healthy people but even through inanimate objects like clothing, it was no wonder that it spread “with the speed of a fire racing through dry or oily substances that happened to be placed within its reach.”¹¹⁸ Could anyone then be blamed for seeking to save his life by fleeing? Is this not what Boccaccio’s ten protagonists do, who while away their time in voluntary exile from Florence by each telling a story on each of ten days (something that plague doctors also recommended in order to take the mind off the plague, as it could be spread by what was called “accidents of the soul”)? So long as he admitted contagion, Boccaccio could not very well come out and explicitly forbid people to flee, as Lubb did; the most he could do was shame them into staying.

Toward the end of the Middle Ages, in fact, the Church finally issued a kind of pronouncement on the morality of flight, which definitively settled the matter in favor of the right of everyone, including priests, to flee the plague. This comes in a little-known treatise residing in the Vatican Archives in Rome entitled Quod liceatpestilentiam fugere (“That it should be permitted to flee the pestilence”), by the Italian bishop of Brescia, Dominico Amanti, who wrote it at the request of the papal cardinal of St. Grisogono, James of Pavia.¹¹⁹ Thus it has the unmistak­able stamp of authority, written apparently in order to settle “some matter of doubt” or debate among “learned and eminent men” on the question of flight, which had evidently existed ever since Boccaccio raised the issue in the Decam­eron. Although the treatise is undated, it was penned between 1464 and 1477 when Amanti was bishop and James was cardinal, and it represents the fullest and most direct treatment of the subject in the medieval Christian West.

It is in the last third of his treatise that Amanti addresses Boccaccio’s objection that flight from the plague “is contrary to [Christian] charity, prayers, and good works.” Amanti concedes that, in his day, “a father abandons his son, and brother abandons brother, and a servant abandons his fellow servant: there is no one who [is left] to console a poor soul” and that this moral failing is perhaps why “pesti­lences rage more frequently [now] than in former times.” However, Amanti re­fuses to conclude from this that flight from the plague will lead to a breakdown of society, since that would impose an impossibly burdensome communal duty upon each individual, such that everyone would need to be a tiller of the land or a builder of houses, because we all need food and shelter to live; by the same logic, even “all of us clerics should get married, because marriage is necessary for the [propagation of the] human race.” Amanti goes so far as to turn the charity argument on its head, pointing out that for a prelate “it would be against charity to not flee [the plague],” since “his death would do great damage to God’s Church.” He also quotes St. Augustine’s De Doctrina Christiana (On Christian Doctrine) for claiming that the order of charity decrees that care of one’s own body take precedence over that of one’s neighbor. The only exception Amanti allows that would prohibit flight is if a pastor would thereby provide a “perni­cious example” to his flock, who would then abandon sick neighbors to their death and despair. But since churchmen can usually arrange for a substitute to do their duties in their absence, this is largely a moot point. In any case, Amanti concludes that the act of flight from the plague is, by its very nature (ex genere), intrinsically good; only the end or circumstance surrounding it can make it bad. What this is, however, must be up to the individual, for the conditions can vary “in terms of place, time, person and many other circumstances.”

In the earlier part of his treatise, Amanti responds to another objection that one also finds in Boccaccio and that is reflected in the Prophetic tradition of Islam, namely, that flight is an attempt “to alter God's design” that had brought the plague in the first place. Here, Amanti is in remarkable sympathy with medical doctors and their theories about the plague. Quoting Avicenna, who taught men “how to recognize pestilential air from its qualities” so that they could then “apply the most preferable remedy, namely flight,” he notes that ani­mals such as kites and storks are accustomed to flee before the “corrupt air” (a very common observation in European plague treatises), so that to deny to hu­mans what is done instinctively by beasts is to set oneself up as “an enemy of nature.” In the same way, “if you refuse anyone the right to flee, it is also neces­sary that you refuse to allow anyone to send for a physician or to seek medica­tions, which is absurd.” On the contrary, medicine is sanctioned by the Bible, and here Amanti quotes from the same “honor the physician” passage from Ec­clesiasticus 38:1—14 that was also used by the Paris medical faculty in their Consultation of 1348 to the king of France.

But Amanti also posits a theological response to the objection, in that he turns it into a discussion of predestination and free will. Those who would fatally resign themselves to facing the plague by not fleeing what had been allegedly decreed by God as a just punishment are like those who deny good works as having any role in human salvation or who are convinced prematurely of their own damnation: just as God may have “decided to save you in this way, namely by your doing good works,” so does God save you when “He has decided to deliver you from the pestilence He has decided that you might be delivered in this way, namely by

fleeing.” Therefore, to deny the option of flight is to deny to humankind the use of his God-given reason, which recognizes “that corrupt air harms a man and that the disease of the pestilence is contagious”; viewed in this way, flight is simply one means by which he chooses to save himself, “since the means by which he ought to do this is his choice, just as if these should be ordained by God.” By implica­tion, then, Amanti accuses those who would resist flight from the plague as guilty of a kind of proto-Protestant heresy. Not only that, they are simpletons and fools, akin to those who in their “silliness” interpret their religion so literally that they take that part of the Lord's prayer, “Give us this day our daily bread,” as meaning they should not work but simply “sit unprepared at table [and wait] for the Lord to send down bread through his angels!”

Finally, there is the last Islamic tenet on the plague to consider that is perhaps best summed up by a writer from Aleppo in northern Palestine who himself suc­cumbed to the Black Death in 1349, al-Wardi:

This plague is for the Muslims a martyrdom and a reward, and for the disbelievers a punishment and a rebuke. When the Muslim endures misfortune, then patience is his worship. It has been established by our Prophet, God bless him and give him peace, that the plague-stricken are martyrs. This noble tradition is true and assures martyrdom. And this secret should be pleasing to the true believer.¹²⁰

Al-Wardi goes on to refute contagion, citing the Prophet's response to the pagan Bedouin (who believed in contagion): “Who infected the first?” In other words, Muhammad was bypassing intermediary causes to ask who infected the first mangy camel, which must have come directly from God. It was also “de­votion to noble tradition,” al-Wardi assures us, that “prevented us from run­ning away from the plague,” for which he apparently paid with his life. But al-Wardi ends his “Essay on the Report of the Pestilence” with a series of sup­plications to God that certainly sounds like he would much rather not be blessed with martyrdom from plague at all, which he describes as an “evil and torture.” This impression is buttressed by the contemporary chronicle of Ibn Kathir from Damascus, who records plague processions and prayers that the crowd hoped and expected would take away the plague, something that one more usually associates with the Christian response to placate an angry God who had sent the plague down as a punishment, for believers and infidels alike.¹²¹ Other fourteenth-century Muslim writers who discuss the Prophetic tradition of plague as a mercy and martyrdom do so in a distinctly ambivalent way. Ibn al-Qayyim, for example, begins his chapter on the plague in his trea­tise on Prophetic medicine with a standard statement that plague is a martyr­dom for every Muslim, but he then goes on to endorse contagion as a second­ary cause of plague much in line with Galenic theories of the spread of disease. Likewise, Lubb only mentions the martyrdom interpretation of the plague in a halfhearted way at the very end of his first fatwa, which otherwise could have cleared up much of the contradictions in the Prophetic tradition regarding contagion that he addresses in earlier sections. It is only with Hajar's plague treatise of the mid-fifteenth century, which was to influence nearly all other treatises that came after it, that we get a strong, unreserved endorsement of the tradition that plague is a martyrdom for believers, to which Hajar devotes an entire chapter.¹²²

According to one scholar, the interpretation that plague was a mercy and martyrdom was “a major theological innovation of Islam” and unique to it, being akin to the promise of paradise for those who waged jihad, or Muslim holy war.¹²³ This is not quite accurate, however. We have already seen how in seventh­century Spain, the promise of the resurrection was held out to those who died of plague in one sermon composed during the First Pandemic, which is somewhat akin to Muslims' positive spin on the plague. An even closer parallel is to be found in the German physician John of Saxony's treatise from the fifteenth cen­tury, in which he states that one of his impediments for treating people with plague was their morbid resignation to death, either due to their belief that “a fixed term of life and death has been established for each individual” or else, even worse, they had “a disposition and desire to die” because “they hoped to go im­mediately to heaven, which is why they did not seek out doctors to prolong their life.” John recalled how during “a certain great pestilence in Montpellier” this happened when “many men chose to die because the pope gave absolution to those dying [from the plague] for their penance and their sins.”¹²⁴

Otherwise, some Christians challenged the notion that plague was always a punishment from God that had to be feared. Petrarch first questioned this in a letter to his friend, Louis Sanctus, in May 1349, when he mused almost blasphe­mously as to whether “could it be perhaps that certain great truths are to be held suspect, that God does not care for mortal men,” since he chooses to punish the current generation in a much harsher way through the plague than our forebears who had sinned equally as much?¹²⁵ Over a century later, Amanti attempted to resolve this conundrum, such as that Job or the children of the sinners of Sodom and Gomorrah were punished even though they were innocent, by pointing to a silver lining to disasters like the plague: For some, he claimed, the disease was a blessing “in that they don't wallow in their sin, for in their wisdom, one is carried off by the plague in order that no evil quality might change their soul.” For others, it inspires them to turn to prayer and penitence that God might save them from the plague, which he does by inspiring his elect to flee!¹²⁶ In a rather innovative theological twist, a Lübeck doctor speculated in 1411 that, since pestilences “can­not be altered by cures, prayers, or other offerings,” it was not a punishment from God but rather his way of gathering “unto Himself those pleasing to Him, that is, young boys and other good people, so that His host with its great numbers may be able to overpower the host of the devil.”¹²⁷ The late medieval English mystic, Julian of Norwich, also came up with an alternative theology to explain why a merciful and loving God would allow evils such as disease: for her it is simply part of God's plan for the ultimate salvation and redemption of the human race, or as she famously puts it, “Synne is behovely [necessary], but alle shalle be wele, and alle shalle be wele, and alle maner of thynge shalle be wele.”¹²⁸

Two other responses to the Black Death, this time exclusively on the part of the Christian community, have also been seen as emblematic of a religious or cultural divide between Christianity and Islam. One is the Flagellant movement, which spread from Austria and Hungary in 1348 westward through Bohemia, central and southern Germany, and Strasbourg before finally ending up in Flan­ders by the late summer and early autumn of 1349. This movement consisted of processions sometimes hundreds strong that would come to town to engage in ritualistic whipping ceremonies that, according to one observer, Heinrich of Herford, might spatter the walls nearby with the Flagellants’ blood and move the spectators to tears.¹²⁹

Traditionally, the Flagellants have been viewed by historians as an apocalyptic or millenarian movement with a radical heretical taint.¹³⁰ One scholar uses this as a pretext for noting a major difference between Christian and Muslim responses to the Black Death: according to Michael Dols, there is no apocalyptic ideology in “orthodox” or Sunni Islam that would have given birth to a Flagellant move­ment.¹³¹ (Shi’ia Islam, however, does have some millenarian tendencies, and to this day flagellation does figure in some Shi’ite commemorations to Husayn ibn Ali during Muharram, the first month of the Islamic calendar.) But in fact, a closer look at the evidence reveals very little support for Christian Flagellants be­ing any more motivated than Muslims would have been by beliefs in an impend­ing apocalypse—nor do I think that guilt over sin played a major role in why the Flagellant movement arose in Europe and not in the Middle East or Spain. Ac­cording to Dols, “There is no doctrine of original sin and of man’s insuperable guilt in Islamic theology,” as there is in Christianity.¹³² Regardless of the truth of this statement, I see it as irrelevant to the raison d’etre behind the Flagellants. For even though the “Christian belief in plague as a divine punishment for men’s sins” certainly underlay why flagellation was chosen as the means by which the Flagel­lants were to achieve their ends, atonement in and of itself does not satisfactorily explain why the Flagellants were performing their whipping ceremonies nor why these were so popular, at least among their supporters.¹³³

As for why Muslims did not also flagellate themselves during the Black Death, the answer may be found not in some esoteric difference in theology but rather in a more eminently practical explanation. The Flagellants participated in an itinerant-based movement that depended on an infusion of fresh recruits as they traveled from town to town. This was simply impractical for Muslim communi­ties if they were to abide by the long-standing Prophetic tradition to not flee to or from a plague-infested area. For all we know, isolated flagellant demonstra­tions may in fact have taken place in the course of Muslim processions against the plague but did not attract the attention of chroniclers because they were not part of a broad-based, wide-ranging movement as in Christian Europe.¹³⁴

Another puzzle is why no scapegoats emerged in Islamic countries during the Black Death, such as we typically find in the Jewish pogroms that occurred in over three hundred towns and other communities in primarily German-speak­ing lands from Switzerland, Alsace, and the Low Countries in the west to Po­land, Bohemia, and Austria in the east between 1348 and 1351.¹³⁵ (Pogroms also occurred in northeastern Spain, southern France, and the Savoy between the spring and autumn of 1348.) It is no longer sufficient to say that Jewish pogroms in Europe were an outgrowth of the Flagellant movement, since the connections between the two are tenuous at best. In terms of timing, Flagellants often arrived in town long after a Jewish pogrom occurred, as was the case in Strasbourg, where two thousand Jews were burnt in February 1349, months before the Flagellants arrived later that year in June or July. We must therefore find some other reason for why such a phenomenon occurred, and why it did so among Christians and not Muslims.¹³⁶

Respective attitudes toward the Jews are irrelevant, in my view, toward ex­plaining the pogroms. Like the Flagellants, the Jewish massacres were really about a desperate attempt to end the Black Death, although certainly medieval Christian “anti-Judaism” helps explain why Jews were targeted. Instead of being a religiously based accusation bound up with the victims' Jewishness, the charge of well poisoning that was leveled against the Jews during the Black Death was part of an entirely rational outlook that was grounded in contemporary medical and scientific theories about the disease that likewise viewed it as primarily caused in the human body by some sort of “poisoning.” The latter were usually interpreted in terms of a naturally occurring causation, such as a “poisonous vapor” ingested into the body from the surrounding air, but a few Christian doc­tors, such as the Spanish physician based at the medical school at Montpellier in southern France Alfonso de Cordoba, did admit of plague poisoning by human agency. These theories were then mutually reinforced by trials against Jews and poor men that charged them with poisoning wells or food in order to spread the Black Death among Christians; these trials first took place in the Languedoc, Provencal, Dauphine, and Savoyard regions of France and Switzerland, all quite close to Cordoba's theater of operations at Montpellier.¹³⁷

If we are right that the poison accusation was primarily about a mistaken hope to end the plague, why then did it not take root in Islamic lands? The answer, I believe, goes back to the Prophetic tradition that plague can only come from the will of God. Even though various authors, such as Khatima, argued for contagion as a secondary natural cause that was not incompatible with this fundamental religious tenet, it would have been another thing entirely to argue that humans themselves could cause the plague by a sheer act of will. This would then place the plague almost entirely out of God's causation, something that no Islamic jurist would stomach. Therefore, it is most unlikely that Muslim jurisprudence would grant the legal imprimatur that had made possible the trials and massacres that we see in Christian Europe. It may be supposed that God could have acted here in­directly by allowing the poisoners to be demonically inspired, as indeed many Christians believed they were, but Muslims usually interpreted the jinn or de­monic influence as acting directly to instill the disease in human beings, not to use them as puppets such as we see alleged during the European witch hunt. A Polish astrologer and physician, Heinrich Ribbeniz, did link an alleged propensity of Jews to poison people with the influence of Saturn during plague that made them more likely to “sin against their gods,”¹³⁸ but Muslim authors of plague treatises were far more skeptical of astrological influences, preferring to adhere to a strict Hippocratic interpretation of plague as arising (secondarily) from unnatural changes in the seasons. For Muslims, the role for humans in terms of acting ac­cording to the free use of their reason came only after plague had been sent down by God: at least, this seems to be the meaning of Umar's parable of grazing cam­els either on the lush or barren slope of the wadi, which he allegedly told to ‘Ubayda during the Plague of ‘Amwas of 638—639.

How to sum up a comparison of Christian and Islamic responses to and in­terpretations of the plague? Any attempt to paint such differences with too broad a brush, as perhaps Dols is guilty of, is criticized these days as failing to take into account the manifold differences of opinions within each religious tradition, at both the popular and intellectual level, and the lack of clarity that this then produces for establishing differences between the two traditions themselves, since points of overlap or obfuscation can always be found.¹³⁹ Certainly, one can un­cover authors on both sides who endorsed contagion, who condoned flight from the plague, and who saw the disease as a mercy, or at least somehow beneficial, for its sufferers. But it would also be false to deny that there weren't differences of emphasis between the two faiths in terms of how they approached the plague. Christian doctors, for instance, were able to endorse contagion unreservedly, without having to take into account religious objections as did their Muslim colleagues. It was also easier for Christian physicians to advise fleeing the plague, since any moral or ethical objections could be overcome simply by prescribing the appropriate medical precautions to take for those who stayed, whether by choice or necessity, as opposed to having to confront a long cultural tradition that frowned upon such behavior. Finally, Christian commentators on the plague were far more willing to question God's direct agency and entertain alternative explanations of the disease, whether these be purely natural causes or human- directed ones. These still made a difference and had an impact upon each soci­ety's experience with the plague, such as why the Flagellant movement or the Jewish pogroms arose in one culture and not in the other.

It also very much mattered how each side expressed itself in taking the posi­tions that they did, even if there were similarities or concurrences between them. Dols has been criticized for insisting on making religious interpretations of the plague emblematic of an entire culture's response to the disease, disregarding other influences.¹⁴⁰ But this is precisely the point: religious responses to plague were all too often bound up with medical, social, psychological, and other cultural considerations, in which the manner of the response indicates how these various perspectives interacted with each other and which had significant consequences for each culture's history with the disease. Bishop Amanti's fifteenth-century trea­tise on flight from the plague is an excellent example of this. I've already noted how much in sympathy Amanti was with the medical agenda of his day, marshal­ing principles enunciated in medical plague treatises in support of his position that flight is a morally acceptable response to plague; he was even willing to equate the medical necessity of flight with a Christian virtue, while any opposition to it was akin to a wrongheaded religious interpretation or worse, heresy. For Amanti, a priest was not even obligated to seek out plague patients to give them last rites, unless their case was incurable or there was no one left to attend them. (This certainly gives some substance to the criticisms of priests' behavior during the Black Death that was made by chroniclers!) One need only contrast this with the hostile attitude toward medicine and the medical profession evident in the Islamic treatises of al-Qayyim in the fourteenth century and Hajar in the fifteenth. Amanti's treatise also supports Dols's contention that Christians were more con­cerned with individual priorities over communal interests, especially when this is compared with the works of Lubb or of the sixteenth-century Ottoman jurist Tashkopruzade.¹⁴¹ The parallel anecdotes told by Gilles li Muisis of Tournai and Ibn Battuta from Morocco (the Christian chronicler relating how some pilgrims “left in great haste” once they learned in the morning that their host and his whole family were dead from plague, while Battuta and his companion stay to pray over and bury a faqir, or Muslim holy man, who had died in their company during the night) neatly illustrate the differences here as well.¹⁴²

Islamic religious hostility toward medicine almost assuredly had wide-ranging consequences for communities facing plague, if one is to go by Khatib's com­plaint “that the quills with which the scholars wrote these fatwas were like swords upon which the Muslims died.”¹⁴³ This is also borne out by the rather less known and studied plague treatise of Khatib's student and fellow physician in Granada, Muhammad ibn ‘Ali ash-Shaquri. Although Shaquri does not encroach upon the thorny issue of contagion in the manner of his teacher, he does come to the defense of medicine as “a sanctuary provided by God and His mercy,” whose practitioners are like “beacons of light in a dark cave” of ignorance and folly.¹⁴⁴ This is rather like Christian doctors who quoted perfunctorily from the “honor the physician” passage in Ecclesiasticus 38:1—14. But Shaquri goes further than this in the following passage:

Many people understand from what is often said that medicine runs counter to God's command, yet there is scarcely anyone more ignorant than the person who makes this claim. The person who violates God's command is the one who hin­ders a created being in any fashion. Obligatory belief in this regard is that medi­cine is among God's commands, and it is among the affairs that He entrusted to His emissary [the Prophet Muhammad], God's peace and prayer upon him. It is also among the blessings and the deeds which God has bestowed upon those who worship Him. It is His command, and thus does He wish it. There is no gainsay­ing His wisdom.¹⁴⁵

Nestled within this spirited defense of medicine is considerable resentment and indignation at those who would oppose medical practitioners out of a mis­guided and blind belief that, by opposing, they are doing God's will, which echoes much of the tone of Shaquri's teacher, Khatib. This is important evidence, I think, of the frustration and obstruction late medieval Muslim doctors had to contend with compared to their Christian colleagues, who did not need to justify their profession to nearly the same extent.

On the other hand, the ease and readiness with which Christian authorities such as Amanti proved willing to conform their religious principles to medical priorities is of great significance for the implementation of plague controls around this same time in northern Italy. By the mid-fifteenth century, and even earlier in the case of Milan, permanent health boards were being set up by some Italian cities in order to be able to respond to plague outbreaks with measures such as quarantine, setting up of sanitary cordons, disinfection or outright de­struction of the living quarters and belongings of plague patients, isolation of the sick and those deemed contagious in their homes or in lazarettos and pesthouses, and so on. Amanti seemed to be signaling that, from his quarter at least, nothing was going to stand in the way of these controls, although mercantile interests in Florence and other Italian republics may have had concerns about their impact on trade.¹⁴⁶ By the seventeenth century, when plague controls were at their height of implementation by health boards across Europe, they began to attract some resistance, even to the point of physical threats made against health board members, due to the intrusiveness, scope, and rigor with which they had been allowed to be imposed, unfettered by any competing cultural considerations except perhaps economic ones. As expected, these protests came largely from the merchant community, who objected to the disruption caused to trade and to the putting-out system of cottage industry, but also from the Church, which, per­haps to its chagrin considering its earlier acquiescence to such controls, now began to be alarmed at restrictions placed upon processions and other religious services during time of plague. Yet, the threat that plague posed to public health was deemed too great, and its controls—directed largely against the poor and other “dangerous” classes at the margins of society—were deemed too effective, to be seriously dislodged; moreover, health boards had much the upper hand over their would-be detractors, backed up as they were by the full force of the law and the power of government apparatuses.¹⁴⁷

By contrast, when Western-style plague controls were introduced into Muslim countries, such as Tunisia in North Africa, by the eighteenth century, their ef­fectiveness was already limited by opposition from the ulema, or religious scholars who spoke on behalf of the Muslim community. This opposition was such that it forced the Tunisian bey to rescind some of the more objectionable measures, such as burning the clothes and possessions of those who had died from the plague. Natives also questioned the medical necessity of plague controls when the disease reappeared in spite of them. Although some Islamic traditions, such as that one must not flee to or from a plague-infected area, might be more compatible with other measures like quarantine, Western observers frequently noted how Muslim attitudes, in particular their fatalistic acceptance of the disease as well as native remedies for plague, differed very much from their own.¹⁴⁸ If one accepts that these controls played a role in the demise of the Second Pandemic of plague,¹⁴⁹ then their greater acceptance in the Christian West as opposed to the Muslim Middle East may help explain why plague ended a hundred years earlier in Eu­rope, by the early eighteenth century, as opposed to the early nineteenth century in North Africa and Palestine. On the other hand, these controls did not come without a price, as those who protested them in both Europe and the Middle East knew all too well. Such conflicts during the Black Death set the stage for even greater clashes between European colonial powers and their native subjects when the former attempted to impose similar controls during the Third Pandemic of plague primarily in India at the turn of the twentieth century.

In other respects, both Muslim and Christian responses to the Black Death followed a familiar pattern that had already been set during the First Pandemic of plague. Such high mortality necessitated mass burials and hurried, disordered funerals: the description by al-Maqrizi of Cairo, of how “funeral processions were so many that they could not file past without bumping into each other” and how the dead were carried to their graves on bare wooden planks or whatever else was to hand, echoes that of John of Ephesus during the plague of 542 in Constanti­nople.¹⁵⁰ Likewise, Marchionne di Coppo Stefani's vivid analogy of how the dead were layered with dirt in mass graves in Florence “just as one makes lasagna with layers of pasta and cheese” rivals John of Ephesus's imagery of the dead being pressed together like in a winepress.¹⁵¹ Prayers and processions of supplication to end the plague again took place as they had during the First Pandemic, even in Islamic cities over the objections of some religious scholars that this went against the traditional view of plague as a mercy and martyrdom for the faithful.¹⁵² Just as the tolling of bells ceased in many European cities as a sign of the plague's disruption of everyday life, so too did the call of muezzins to prayer in Cairo or Damascus, although the latter did not go so far as to deliberately constrain or even ban commemorative and religious services in line with medical prescriptions against the plague that we find contained in some European ordinances passed in response to the Black Death. And there were people who found a way to profit from the plague in both Christian and Muslim lands, whether these are the bec­chini who carted away the dead for fat fees in Florence or the readers of the Qur'an who now made ten dirhams per funeral in Cairo.¹⁵³

However, there is one area in which I believe Europe had a cultural advantage over the Middle East in terms of addressing plague, aside from its greater propen­sity for medical plague controls. This relates to each culture's attitudes toward and beliefs in the afterlife. Medieval Europe during the Second Pandemic had a re­markably concrete, palpably tangible conceptualization of the afterlife, one that was quite possibly unique in all of recorded history. One only has to read Dante's Divine Comedy from the early fourteenth century, just before the arrival of the great outbreak of plague in 1348, to understand just how fully articulated and profoundly real this conceptualization was to our medieval forebears. Purgatory, in particular, was ideally suited to a “cult of remembrance” of the dead, in which the dead were assured that they would not be forgotten among the living in their prayers and the living were comforted with the promise that death was not the end but just the beginning of their spiritual journey, a journey that would end only with the Last Judgment when bodies ravaged by disease would finally tri­umph over death by being resurrected whole and sound to rejoin their souls. This cult of remembrance so intimately bound up with the concept of purgatory was bound to be attractive at a time of plague when its mass death threatened to con­sign all to oblivion in a common grave. Purgatory, which was “invented” by the Western Church in the late twelfth or early thirteenth century and which is de­scribed by Dante as a great mountain of nine terraces, was completely foreign to Hebraic and Muslim cultures, even though they too had their versions of final judgment and resurrection. Europe's late medieval cult of remembrance is well attested by the wills proved in central Italy and in Douai in Flanders during the second half of the fourteenth and during the fifteenth centuries, when a greater percentage of them in the aftermath of plague specify some kind of commemora­tion, such as individual portraiture in tomb sculptures or within larger artistic commissions.¹⁵⁴ Thus, when facing a uniquely mortal disease like plague, which portended for its many victims a swift and sudden demise, Europe's “death­friendly” culture, I would argue, with its detailed topography of purgatory and elaborate preparations for death in this life, was uniquely equipped for the psy­chological challenge posed by plague compared to the belief systems in place in the Middle East and in other regions around the world.¹⁵⁵

Finally, there is the differential economic impact of the plague in Europe and the Middle East. This is a question that recent scholars have tried to tease out from the thorny issue of how differences in religious culture between Christian­ity and Islam played themselves out during the plague, although, as we will see, economic factors cannot be so easily disentangled from other considerations such as the social and political makeup of societies.¹⁵⁶ Mortality during the Black Death is thought to have been at least as severe in the Middle East as in Europe: even though considerably fewer archival resources are available in the former region, enough has been recovered from sources such as cadastral surveys in Egypt to suggest that the two were comparable.¹⁵⁷ Traditionally, the assumption then followed, largely based on chronicle accounts, that the economic trajectory of the Middle East followed that of Europe's in the aftermath of the Black Death, despite the fact that, by the end of the Middle Ages, Europe, and England in particular, had emerged with its economy poised to take full advantage of the benefits of a new, capitalist-based system, while that of the Mamluk dynasty in Egypt, for example, lay in ruins.¹⁵⁸ New research on Egyptian sources such as endowment deeds and chancery manuals that supplement narrative chronicles has greatly revised this comparative picture.¹⁵⁹

A comparison of England's economic response to the plague with Egypt's over the course of the fourteenth and fifteenth centuries reveals that the two were diametrically opposite: in England, the long-term economic impact of the mas­sive depopulation caused by successive waves of the plague led to growing pros­perity in the population at large (with the significant exception of the landhold­ing class), since, in general, wages of laborers rose, prices of agricultural necessities fell, and rents declined, all tending to raise peasant incomes and spelling the end of the oppressive manorial system; however, in Egypt, the reverse was true, with wages falling, grain prices rising, and rents increasing, all leading to the collapse of the economy based on fellahin labor. A simple comparison of the agrarian GDP (gross domestic product) in the two countries by the early sixteenth cen­tury, after they had started out on roughly equivalent terms before the Black Death during the early fourteenth century, dramatically illustrates the disparity: Egypt's fell by nearly 60 percent during this period, while England's recovered and actually increased by 7 percent, so that England's GDP was by this time double that of Egypt's.¹⁶⁰

Obviously, a catastrophic mortality from the plague occurred in both coun­tries that triggered these changes but not with the same result since very different social and political circumstances then interacted with and responded to the demographic decline. In Egypt, the Mamluk military elite that ruled the country from Cairo owned the iqta landholdings in the countryside (which were not the same as fiefs in Europe) on a nonhereditary, unstable basis and administered them through an elaborate bureaucracy that discouraged personal supervision and control. Furthermore, the Mamluk caste of soldiery was able to respond to the disruptions caused by the plague as a cohesive, unified body, or “collective bargaining unit,” that successfully suppressed any attempts by the fellahin to take advantage of greater demands for their labor that was now much more scarce in the aftermath of the Black Death. Additionally, the complex irrigation network that maintained Egypt's agricultural estates along the Nile River valley was a highly labor-intensive system that inevitably suffered from population declines inaugurated by the plague but that was now largely administered by emirs pursu­ing their private self-interest instead of by the central government of the sultan. This irrigation system also suffered from Bedouin incursions in the outlying districts. Thus, a combination of unique political, social, and geographical cir­cumstances led to the decay in Egypt's agriculture throughout the late Middle Ages in response to the Black Death.¹⁶¹

By contrast, in England and elsewhere in Europe, feudalism ensured a decen­tralized, local control over landholdings such that, despite the aristocracy's best efforts at passing labor legislation in national parliaments, peasant communities were the ones who were able to bargain more effectively as a collective unit by taking advantage of landholders' rivalry and economic competition with each other. Despite the fact that, from the elite's point of view, Egypt's autocratic re­sponse was far more preferable, in the long run and with hindsight it was Eu­rope's seemingly chaotic, socially undermining response that held the greatest overall economic benefits for its population, one that set the stage for its rise and dominance over the Middle East in the modern era. The economic winners and losers from plague were therefore determined not just by the disease's mortality itself but also by its interaction with a whole host of factors that were unique to each society, ones not necessarily bound up with its religious culture. These eco­nomic benefits and costs were also not necessarily intended or foreseen at the time; in fact, a society or culture may have been straining for exactly the opposite result. There is some question remaining, however, as to whether a comparative case study such as that between Egypt and England can hold true for entire re­gions or continents, that is, Europe versus the Middle East. Were Egypt's circum­stances the same as those in Syria or Iran?¹⁶² Was England's drive toward a renter, capitalistic economy by the fifteenth century mirrored in Spain, Italy, or Eastern Europe? The evidence suggests rather that even within a geographic entity that shared a similar set of cultural values, such as Christian ethics and feudal and manorial landholding systems, variations could still occur in terms of the eco­nomic impact of the Black Death. But at least it is clear now that Europe and the Middle East could differ dramatically in terms of their respective responses to plague in more ways than just along the religious divide traditionally demar­cated between the two cultures.

A last legacy of the Second Pandemic of plague to consider is how both Chris­tian and Muslim chroniclers personified the disease in their writings, perhaps as an indication of just how feared the plague was by premodern societies. An anonymous doctor writing from Lübeck in Germany in 1411 called plague the “[evil] stepmother of the human race” due to the way it carried off “too many” of his friends and fellow citizens; rather than characterizing the disease as an “ill­ness,” he called it simply a “death.”¹⁶³ He and another fifteenth-century German doctor, Primus of Gorlitz, also portrayed plague as an enemy to be fought and hopefully conquered by their regimens; in the former case, the physician’s victory over plague apostemes was compared to banners raised on castle turrets to signify surrender.¹⁶⁴ In his more poetic passages, the Muslim Syrian writer al-Wardi compared the Black Death variously to a lion, a silkworm, a storm, a taxpayer, a king who “swayed with power” on his throne, and a lover who poisons her vic­tims as she kisses and embraces them. In another passage, the plague enters a house as if it were the agent of the qadi, or religious judge, announcing that it was there to “arrest” all those within.¹⁶⁵ Clearly for our ancestors, plague had become all too personal and real. Their fear of the disease stemmed not only from its high mortality but also from the horribly painful way in which it killed (at least in the bubonic form) and the sudden swiftness of its grim harvest (par­ticularly in the pneumonic and septicemic forms), which left precious little time for preparation for the afterlife. This literary treatment of the plague set it apart from all other diseases and accorded it a special place in human history.

The Third Pandemic of plague apparently began as early as 1854 in the Yun­nan province of southwestern China, spreading from there to other Chinese provinces until it eventually arrived at the ports of Canton and Hong Kong in 1894.¹⁶⁶ Two years later, it called at the port of Bombay in India and then spread particularly to the northern and western regions of the country and decimated approximately twelve million of the native population by 1930, comprising 95 percent of the world’s mortality from the pandemic. Another major outbreak in Asia came in Manchuria in northeastern China, where the disease manifested it­self as exclusively pneumonic plague and swept away 60,000 inhabitants in 1910-1911 and 8,500 more in 1920-1921. By the turn of the twentieth century, largely through the power of modern steamship transport, plague made its way around the world, infecting and establishing new endemic centers in Madagascar and South Africa, Southeast Asia, South America, Russia, and Australia, often in defiance of local quarantine measures.¹⁶⁷ In 1900, plague called at San Francisco and from there spread throughout the western United States, where it has an endemic presence down to the present day, as shown by the case of Tull and Marker mentioned at the beginning of this chapter. The continued relevance of plague is also demonstrated by recent epidemics in Surat, India, and in Madagas­car, where a new, antibiotic-resistant strain of Yersiniapestis has emerged.

The Third Pandemic presented microbiologists with an unprecedented, golden opportunity to study plague using the new tools of modern science, in this case, that of bacteriology and the germ theory of disease, as inaugurated earlier in the nineteenth century by such pioneers as Louis Pasteur and Robert Koch. A student of Pasteur's, Alexandre Yersin, is credited with being the first to discover the bacil­lus that causes plague in both rodents and humans (hence its name, Yersinia pes­tis). The rat-flea nexus that spreads the bacteria in cases of bubonic plague was then explained by another protege of Pasteur's, the French bacteriologist Paul- Louis Simond. Special research bodies were also set up to study the disease and publish their results, including the Indian Plague Commission, which issued a Minutes of Evidence and Report in 1900—1901, supplemented by annual articles in the Journal of Hygiene between 1906 and 1937, and the North Manchurian Plague Prevention Service, which came out with three Reports on the plague in Manchuria between 1914 and 1922. However, it would be a mistake to assume that these “scientific” reports on the Third Pandemic are all entirely trustworthy or characterize the behavior of the plague in all places and at all times. Like any other document, they are a product of their specific historical context, and some of their assertions, such as that plague was communicated through the soles of the feet or that “one of the safest places during an epidemic is the ward of a sanitary plague hospital,” were motivated primarily by political or racial considerations and are therefore misleading or outright wrong.

Of more interest to scholars of the Third Pandemic have been the cultural conflicts that emerged between colonial authorities such as Britain who were trying to implement modern, Western-style plague controls and medical ideas in their empires, and the native subjects in India and elsewhere who bore the brunt of this so-called disease imperialism.¹⁶⁸ Some of the issues here also crop up in the British government's handling of other diseases that threatened India, such as smallpox and cholera (chapters 2 and 4), but plague presented a unique con­catenation of circumstances: the Third Pandemic proved to be an intriguing in­tersection of a long history of dealing with plague in both Europe and Asia combined with a new knowledge and awareness of how the disease was actually caused and spread. Imperial powers such as Britain wielded the weapons of mod­ern medical science almost like a club, determined to bludgeon its Indian empire into health on the conviction that it could now finally eradicate an age-old dis-

ease. Yet, this newfound and arguably unprecedented determination to collec­tively cure a nation came up against an equally determined native resistance in India, and to some extent this was also true of the response of Chinese authori­ties to the pneumonic plague outbreak in Manchuria.¹⁶⁹ While scholars have typically explored the Third Pandemic for its political ramifications in terms of Britain's and Europe's colonial policies, our concern here is more strictly epide­miological: did the modern “scientific” effort against plague work, and if not, why? Somewhat to their surprise, British authorities discovered that their ener­getic efforts to combat the plague—which initially included compulsory hospi­talization of all patients who had come down with plague, segregation of con­tacts, house-to-house searches and disinfection of all homes where plague occurred, and inspection of plague corpses—could be stymied by the bitter op­position of natives, which was bolstered when a recrudescence of plague occurred during the late summer of 1897 despite the apparent success in temporarily halt­ing the 1896 outbreak. This required a new policy from the British government by 1898—1899 of accommodation to native customs and sensibilities, which proved to be a more effective response to the disease.

Nonetheless, some larger questions remain: Was the British failure to contain the epidemic in 1896—1897 simply a function of insensitive imperialism, or were its policies, which had much in common with those adopted by European health boards during the Second Pandemic, when the disease was understood to be miasmatic rather than microbial in character, truly suited to fight the spread of plague germs? Could native responses, such as evacuation and flight from areas where plague (as well as its oppressive controls) occurred, have actually been more effective in breaking the chain of the flea-rat-human connection that spread bubonic plague? How did this dynamic play out in China, where Western medical approaches were implemented by native ruling elites after 1894 (osten­sibly in order to co-opt foreign interference) and where there was a more straightforward, human-to-human contagion of pneumonic plague? Was the native popular resistance to antiplague measures, whether in India or China, motivated by colonial resentment toward a Western imperialist foreign influ­ence, by a traditional distrust of modern innovations, or simply as part of a “generalized panic” in response to a truly horrific disease like plague? And what lessons do all these issues hold for current efforts to fight our own emerging pandemics, such as avian influenza or swine flu?

It is remarkable how, despite all the new advances and information that emerged during the Third Pandemic with respect to identifying the causative microorganism behind plague and explaining its transmission, the actual mea­sures taken by modern medical authorities against the disease in both India and China mirrored those adopted by European health boards during the Second Pandemic primarily between the fifteenth and seventeenth centuries. As during the late medieval and Early Modern periods, authorities implementing anti­plague measures during the Third Pandemic often felt stymied and frustrated by the perceived ignorance, superstition, and at least passive resistance of the masses they were trying to help. Even in China, where native authorities had better compliance from their subject population than the British medical service had in India, resistance to such measures as hospitalization of victims and isolation of contacts could be significant. Dr. Wu Liande, chief medical officer of the North Manchurian Plague Prevention Service, who was put in charge of all Chinese efforts to contain the pneumonic plague outbreaks in Manchuria and who re­ceived his medical training at the University of Cambridge in England, com­plained that “one of the most difficult problems of plague-prevention in China was this passive opposition of the populace in not reporting cases when alive and then throwing the bodies out when dead.” This happened even among “well­to-do and educated persons,” and Wu frankly admitted that it hindered his ef­forts at fighting plague, for “if there had been cooperation between the public and the authorities at the beginning, the epidemic would have been more con­fined, but the cases were hidden and the families or friends were thus infected.” However, Wu also allowed that there was at least a culturally, if not medically, valid reason for why his Chinese subjects refused to cooperate in this regard, which was their fear of isolation from their families, whose importance had been stressed in China going back to the philosopher Confucius during the sixth and fifth centuries B.C.E. “This fear of isolation,” Wu wrote, was prevalent through­out the country, “in North and South China alike”¹⁷⁰—nor can the masses really be blamed for harboring such fears when patients were doomed to spend their last days in the solitary confinement of what even Wu described as stark, “puri­tan-like” hospital rooms with only a cast-iron bed and spittoon for company, all the while tended by masked and therefore faceless attendants, and when isolation wards for healthy contacts consisted of railway boxcars normally fit only for car­rying freight but that were left idle during the quarantine imposed by the plague. When plague hospitals, such as the one at Harbin, are also described as sur­rounded by barbed wire and posted armed guards to keep their infectious resi­dents from escaping, one can be forgiven for comparing their general atmosphere and conditions to that of prisons for the most hopelessly condemned.¹⁷¹

Likewise in India, even the most well-intentioned, well-thought-out precau­tions against plague could be stonewalled or undone altogether by native resis­tance, which included substituting healthy people for sick ones in roll calls, hiding corpses in dust heaps, and inducing native doctors to diagnose victims as suffering from asthma or bronchitis instead of plague. Even worse, from the authorities’ point of view, was inducing friends or relatives to hide plague victims from their prying eyes, since plague was still deemed to be contagious, even though this is not strictly true in the case of bubonic plague (unless patients develop secondary plague pneumonia). It also must have been most demoraliz­ing for the British Civil Service in India to hear of “plague rumors,” not all of which were unjustified and which arguably reflected a very real terror of plague: these included that British medical staff at plague hospitals and segregation camps poisoned native patients, stole their possessions, forcibly carted away healthy persons for extortion purposes or else compelled them to be guinea pigs for inoculation trials, and even that they cut up native bodies and boiled them down to extract a healing balm known as momiai)-¹¹ (Manchuria also had its share of these plague rumors during the 1920—1921 outbreak, such as that Wu's staff put poison in people's wells, flour, and other food in order to collect the three-dollar reward for each corpse supposedly dead of plague, and that Wu himself was said to be secretly shooting the sick behind the walls of his plague hospital at Harbin.¹⁷³) The French colony of Senegal in West Africa, where a major epidemic of bubonic plague occurred in 1914, presents a third example of how native resistance to antiplague measures could force a compromise in colo­nial policies, especially when the mother country faced the simultaneous pressure of just having entered the First World War. Here, the paternalistic medical re­sponse of the French government included quarantine and residential segrega­tion, disinfection and burning of affected houses, and mandatory vaccination, while the native resistance, characterized as “the most militant popular opposi­tion” in the colony's history, included mass street protests and general strikes among market sellers of produce.¹⁷⁴

But since the dynamics of bubonic plague (spread by rats and fleas) are so very different from pneumonic plague (communicated by human-to-human con­tact), one can question the relative effectiveness of such measures as quarantine and disinfection in India, China, and Senegal. Whereas Wu was able to slash the number of deaths to less than a sixth of their former total after a decade of fight­ing pneumonic plague in Manchuria, India at least initially had rather less suc­cess, since half of all its deaths from bubonic plague occurred during its first ten years of living with the disease from 1898 to 1908. Indeed, the fact that India's antiplague measures were basically unchanged from the Second Pandemic indi­cates that they were adopted by the British out of long habit and expectation (their “traditional” response in the same way that the natives had theirs), rather than being specifically formulated to meet the new realities of the germ theory and their spread by insect and rodent vectors. This also seems to have been the case in Senegal in 1914, where medical authorities placed very low priority on disrupting flea and rat infestations of straw huts and granaries in both city and countryside.¹⁷⁵ By the same token, this leads one to question whether human attempts to control plague had any role at all in ending the Second Pandemic, or was it rather due to independent biological factors, such as emerging rat im­munity to the disease, that had nothing to do with the human response?¹⁷⁶ Disinfecting homes and burning clothes and bedding undoubtedly helped re­duce the number of fleas that could communicate bubonic plague, but this may also have unintentionally driven rats to seek the shelter of other dwellings, where they then continued to spread the disease. The only truly effective means of breaking the chain of connection between plague-infected rats and fleas and their potential human hosts, the Indian Plague Commission found, was the long-standing tradition that native Indians already had of evacuating to the sur­rounding countryside whenever the disease broke out in their villages.

As in China, authorities in India also underestimated the strength of family ties that bitterly resisted any attempt to separate members of a household once plague was discovered there. The broad powers that the British government arrogated to itself by the terms of the Epidemic Diseases Act passed in February 1897 in order to segregate and hospitalize anyone tainted by the plague provoked an outcry of native protest. One native newspaper in Pune, the Burdwan Sanjivani, declared that, no matter how justified such measures might be in sacrificing individual needs for the general welfare, “few will desire to live in a country where the wife is separated from the husband, the child from the parent, and the parent from the child. We call this selfishness, and not self-sacrifice.”¹⁷⁷ Indeed, according to an­other native newspaper, the Vyapari, “The moral effect of segregation alone, apart from the character of the arrangements at the segregation hospital, is sufficient to retard the recovery of a patient compulsorily removed from among his relations.”¹⁷⁸ This contradicted the testimony of some of the British agents who appeared be­fore the Indian Plague Commission, such as Colonel Donald Robertson from the Mysore state and Major G. E. Hyde-Cates of Cutch, who alleged that some na­tives abandoned their relatives, to the point that mothers even refused to nurse their children, once they were infected with plague.¹⁷⁹ Yet, this is so similar to what European chroniclers were saying of family behavior during the Black Death that it begs the question of whether modern observations (at least those made from a Western point of view) were conditioned by what was known of the earlier Second Pandemic? Or rather, were such cases of abandonment an extreme re­sponse, not at all indicative of the behavior of the population at large, that none­theless drew the attention of many observers during both pandemics? For all the data generated by its modern, scientific approach to the disease, in many ways the Third Pandemic raises more questions, both with respect to its own experience of plague and that of the past, than it answers.

Finally, the Third Pandemic has been portrayed by its historians as a classic example of Western imperialism imposing its concepts of medicine and disease upon the colonial subjects of its empires, but is this really or entirely the case? It has been fairly pointed out that the native Indian response to plague and to the draconian measures imposed by the British government was a complex one that did not always fall along neatly antagonistic lines.¹⁸⁰ Nonetheless, some elements of how the disease played out particularly in India do suggest that resistance to plague was tantamount to resistance to imperialism. Most obvious in this regard was the assassination on June 22, 1897, of the British Civil Service officer, W C. Rand, who was in charge of enforcing plague-prevention measures in Pune. Rand had, in effect, become a symbol of oppressive, “white bull” British rule in India, for he had a notorious reputation for carrying out measures such as house inspection in a brutally harsh and offensive manner, which contrasted with more enlightened regimes such as that of General W F. Gatacre in Bombay. (Rand boasted that his efforts to control plague “were perhaps the most drastic that had ever been taken to stamp out an epidemic.”¹⁸¹) The editors of one native news­paper in Pune, Dnyan Prakash, concluded that Rand's Plague Committee had no other motive for its actions than that they were being done “for tyranny's sake— for no other reason save that the members of that body take a peculiar delight in making the citizens feel their power.”¹⁸² Certainly a connection between plague controls and imperialist policies existed in the minds of some British authorities, such as W. L. Reade, the medical officer who eventually succeeded Rand as the man in charge of plague operations at Pune. In a letter to his superiors back in London, Reade frankly confessed that “plague operations, properly undertaken, present one of the best opportunities for riveting our rule in India, as it is not only an opportunity for showing a kindness to the people, but also for showing the superiority of our Western Science, and thoroughness.”¹⁸³ Clearly for Reade, conquering the plague and the allegiance of native Indians to the British Empire went hand in hand, even though he certainly presented an overly optimistic view of how well plague controls were working and the natives' reception of them for the benefit of the India Office back home, as well as for the sake of his own self­promotion. Some native newspapers also made this connection quite explicit, such as when Poona Vaibhav, responding to the passing of the Epidemic Diseases Act in February 1897, stated that, “if [the British] government under such cir­cumstances will oppress people in the shape of plague preventive measures and pass laws giving ample powers to their officers to carry them out, there is every probability that the government and the people will be the bitterest enemies of each other.” The paper also issued a thinly veiled warning to British authorities by calling to mind the numerous “examples in Indian history of oppressive re­gimes being overthrown through agencies sent by God for the deliverance of the oppressed,” a reference, perhaps, to the not-so-distant Sepoy Mutiny of 1857; other papers sardonically paraded similar examples of resistance to tyranny from Britain's own history, such as when the barons of England forced King John to sign Magna Carta in 1215.¹⁸⁴

However, as Reade's letter makes clear, British imperialist intentions with re­spect to the plague were inseparable from the supposed technological superiority of modern Western medicine when compared to what was available from native traditional healers, the Hindu vaids and Muslim hakims. (This in spite of the fact that the British response of plague controls could be considered just as tradi­tional, in the European context of the Second Pandemic, as the Indian one.) In this sense, then, it did not matter who administered the antiplague measures so much as that they were alien to a people's customary way of life and culture. This much is clear from the fact that resistance blossomed even in China, where plague controls were administered by native agents (albeit, in Wu's case, one who had been heavily influenced by Western ideas, as transmitted through his Cam­bridge training). A revealing anecdote from Wu is when he unfavorably com­pares his own people to the Japanese, whom he praises for overcoming their fear of plague controls such as isolation due to the fact that the “new universal educa­tion of the masses produced its beneficial results.” To counter the sometimes violent resistance of the mob, which included gun and knife threats made against members of his staff, Wu authorized the publication of “thousands of circulars,” as well as a daily newspaper, giving details of the service's ongoing fight against the epidemic. In addition, Wu's assistants “gave public lectures whenever possible and answered any questions that might be asked them by their audience” as part of his own education offensive in Manchuria.¹⁸⁵ Wu's counterpart in India was Dr. U. L. Desai, a native physician also educated in England posted at the plague hospital in Nasik, who recommended farther reaching measures against the plague than even the British Civil Service was willing to contemplate, to include improvements in sewage systems, better housing, educational schemes to pro­mote hygiene, and compulsory registration of all medical practitioners, aimed particularly at native vaids and hakims.¹⁸⁶ Some native newspapers also sided with the British government by urging their readers to submit to plague mea­sures, even if they be distasteful, for the greater good of the public health. On the other hand, when newspapers did advance people's objections to such mea­sures, many did so primarily from a cultural, rather than colonial, point of view. The Bangavasi of Pune, for example, cited a Hindu fatalism toward disease, somewhat akin to the Muslim one reported in Tunisia, when it rhetorically asked its readers, “Why prevent the helpless and long suffering Hindu from dying in peace? When death summons us we must die. Why disturb and distract us in the name of science?”¹⁸⁷ When Vydpdri objected to plague measures such as “the limewashing of houses, the destruction of huts, [and] the compulsory segrega­tion of plague patients,” which it characterized as “nothing but folly and mad­ness,” it likewise did so on the grounds that modern medicine was foreign to native customs and beliefs:

These may be the most approved means, according to Western sanitary science, of stamping out the plague, but it will be very difficult to persuade an orthodox Native to believe in their efficacy. Our people, who are brought up in the old order of ideas, generally look upon such epidemic diseases as the result of Divine displeasure and so they seek to suppress them by offering oblations to the Deity and so forth.

Since “no one knows anything for certain about the plague and the proper means of suppressing it,” the editors felt that the government’s efforts as of Feb­ruary 1897 were a laughable “misdirection of energy.”¹⁸⁸

A third view, however, claims that native objections to Western science and medicine as represented by British plague controls in India were not based on an inveterately hostile cultural response, which was never “uniform” or “homoge­nous” in any case, but rather on the fact that, even though it had now entered a promising new era, the modern medical tradition of the West was too often simply ineffective and incapable of curing or preventing the plague. When acces­sible and accommodating to native sensibilities, locals could in fact prove them­selves quite willing to avail themselves of Western doctors and hospitals. This suggests that the political and cultural dynamics of the Third Pandemic in India were conditioned primarily by the disease of plague itself, which due to its uniquely dramatic history (particularly during the Black Death) and characteris­tics, set off a “panic” both in the British government and among its native sub­jects, who had to respond not only to the plague but also to the unusually op­pressive measures devised to contain it.¹⁸⁹ If true, such an interpretation would imply a continuity of historical responses to plague, but a possible objection is that native protests to plague controls in India were not exactly comparable to those made in Italy during the Second Pandemic, since the latter were based primarily on economic, rather than medical or cultural, grounds.

Although the case studies in India, China, and Senegal during the Third Pan­demic of plague are the most studied and well known, the dynamics of modern efforts to control plague likewise played out at ports of call all around the world. For instance, significant native resistance to plague controls imposed by imperial or Western-leaning governments occurred in the British colony of Hong Kong in 1894; at Rio de Janeiro in Brazil, Honolulu in Hawaii, and San Francisco in the United States in 1900; and at Cape Town in South Africa in 1901. However, at Alexandria in Egypt and Sydney in Australia, plague’s impact was minimal, and resistance to antiplague measures was muted in 1899—1900; in the former case, this was perhaps because the native Muslim medical tradition was somewhat compatible with the West’s and the government’s health policy respected its population’s pluralistic culture, while in the latter case, health authorities eventu­ally shifted their focus to controlling the rodent population rather than quarantin­ing the human one, which proved to be a more enlightened approach to combat­ing plague. At Rio de Janeiro, Cape Town, Honolulu, and San Francisco, there was a markedly racial element to authorities’ plague measures, which dispropor­tionately targeted native people of color and immigrant Chinese. In Rio, both the government’s policies toward plague and popular resistance to them, which ended with the demolition of the Afro-Brazilian district of the city, were influenced by roughly concurrent measures against two other diseases, yellow fever and small­pox. Honolulu’s Chinatown was accidentally destroyed by a fire set initially as a “controlled burn” to contain plague and for which the U.S. government never adequately compensated its victims. The forced segregation of black Africans by the British in Cape Town became an important precedent for the later apartheid policy in South Africa. And in both Buenos Aires, Argentina, and in San Fran­cisco, authorities engaged in a counterproductive denial of the existence of plague, with the collusion of the local press.¹⁹⁰

One of the three general lessons to be learned from all three pandemics of plague, and which we will see apply to other diseases as well, is therefore this one: that throughout the ages and into the foreseeable future, medicine will be limited in terms of its effectiveness in fighting some diseases, like plague. While modern medicine has proven its ability to eradicate certain illnesses, such as smallpox (discussed in the next chapter), a disease like plague is too extensively endemic in too many places around the world to simply disappear from human history. This, of course, is not even counting the fact that newly emerging diseases, like the 2009 swine flu pandemic, will always arise to challenge medicine and that even older diseases like plague and tuberculosis can mutate into drug-resistant strains to elude our cures. But even when medicine was woefully impotent against plague, as it was during the First and Second Pandemics, doctors were still convinced they could make headway against the disease, and who knows, with some measures like self-imposed quarantine and mass evacuation that were adopted by Venice during a plague in 1576, perhaps they did.¹⁹¹ In turn, modern medicine during the Third Pandemic learned to be humble in the face of plague, when its very response to the disease, even when armed with its new knowledge about germs, provoked a reaction from its would-be patients that proved coun­terproductive to its efforts. Modern medicine thus needs to strike a balance with diseases like plague, particularly when its “miracle cures,” like vaccination or antibiotics, prove ineffective or are not at hand, so that it will be forced to fall back on what are now “traditional” measures, like quarantine. How will modern society react to such outdated methods to control disease when these may seem as culturally foreign and objectionable as the British plague hospitals did to na­tive Indians during the Third Pandemic? Certain implications of plague controls, such as that family members might become separated or that economic liveli­hoods may be disrupted, probably will always be protested no matter how cul­turally predisposed a civilization or society is to them. This past year, for example, the Vermont department of health asked my wife and I in a phone survey if we would be willing to quarantine ourselves in our home for a whole month should an untreatable flu outbreak occur. While we have no ideological objections to such a measure, it did raise some eminently practical questions, like how would we stock up on enough food and survive an enforced unemployment for such a lengthy period of time? Our society, and each individual within it, will have to decide how far it is willing to go in order to safeguard itself from a terrifying, “plague-like” disease.

The second lesson of plague is that a disease that can follow in the wake of either animal or human migrations will always be global in scope, insofar as this is defined by the trade and travel patterns of the times. During the First Pan­demic, plague was largely delineated by the sea networks of the Mediterranean region; during the Second Pandemic, by the overland trade routes of the Mongol Empire across Eurasia; and during the Third Pandemic and into modern times, there now seems to be no geographical limit to disease, what with the global reach of ship and airplane transport. So what once used to be a localized out­break in some exotic corner of the globe is now our backyard epidemic. This necessitates, of course, ever greater and more sophisticated vigilance to try to contain pandemics, only to be led by agencies with transnational authority and clout, such as the World Health Organization (WHO). We can only hope they are up to the challenge.

The third and last lesson of plague is how there are always winners and losers to disease, both within a given society or culture and between rival civilizations. During all three pandemics, some civilizations appeared to benefit from, or at least tried to profit by, the plague: the Islamic Umayyad caliphate rose to power during the First Pandemic; Europe emerged economically and technologically superior to the Middle East by the end of the Second Pandemic; and the British Empire attempted to cement its rule in India during the Third Pandemic. In England during the Black Death, the peasant classes seemed to benefit economi­cally the most from the plague, while the opposite was true in Egypt. Yet, these impacts were, for the most part, entirely unpredictable. When the British Civil Service, for example, intentionally tried to use the Third Pandemic as an oppor­tunity to demonstrate the medical benefits of the empire and so further its influ­ence among its native subjects, what it ended up with was, in the words of one scholar, “the greatest upsurge of public resistance to Western medicine and sanita­tion that nineteenth-century India had witnessed,” such that it represented “a profound crisis for... the power of the colonial state.”¹⁹² While plague and its controls instilled chaos, terror, and social tensions in towns and villages across India that brought everyday life to a standstill, some disreputable elements were nonetheless able to benefit by means of extortion and crime.¹⁹³ By contrast, when the government of medieval England tried and failed to turn the clock back on the economic effects of the Black Death through its labor legislation, it benefited enormously from the economic power unleashed from its eventually liberated peasantry. With such unintended results as these, who indeed would wish to be visited by plague in the hope that somehow they will be the victor by it?

Of one thing we can be certain: plague, the most dramatic of all diseases in terms of its absolute mortality, has also had the most drastic cultural impacts upon the civilization or society that was made to feel, whether for good or ill, its wrath.