Covino venice new york times

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Table of Contents

Title Page

Dedication Introduction INTRODUCTION CHAPTER 1 - THE SENSE OF AN EPIDEMIC CHAPTER 2 - PLAGUE: BIRTH OF THE MODEL EPIDEMIC

THE COMING OF PLAGUE TO EUROPE DISEASE AND FEARS OF CONSPIRACY PLAGUE AND VIOLENCE TOWARD JEWS ILLNESS AND FAITH PLAGUE AND THE GROWTH OF THE STATE “BLACK DEATH”

CHAPTER 3 - CHOLERA, POVERTY, AND THE POLITICIZED EPIDEMIC

CHOLERA’S BEGINNINGS A DISEASE OF THE POOR THE POLITICAL TRANSFORMATION OF ILLNESS MIASMA AND THE RISE OF SCIENCE CHOLERA AND UTILITARIANISM CHOLERA IN AMERICA ILLNESS AND IMMIGRATION

CHAPTER 4 - GERMS, SCIENCE, AND THE STRANGER

GERM THEORY VICTORIOUS THE BIRTH AND GROWTH OF EPIDEMIOLOGY MICROBIOLOGY’S DEBUT EVOLUTION, SOCIAL DARWINISM, AND THE CARRIER GERMS IN AMERICA GERMS, FLU, AND FEAR THE AFTERMATH OF GERM THEORY

CHAPTER 5 - THE CONQUEST OF CONTAGION

PROGRESSIVISM AND MORALISM GERMS AND THE SEXUAL REVOLUTION “YOU CANNOT HAVE OMELETTES WITHOUT BREAKING EGGS”

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BEYOND EUGENICS BEYOND GERM THEORY

CHAPTER 6 - POSTMODERN EPIDEMICS

AN EXTRAORDINARY EPIDEMIC DEBATES ABOUT DEVIANCE THE MIXING OF CAUSE AND EFFECT THE BEHAVIORAL TURN: EDUCATION AS POLICY EDUCATION IN LIEU OF POLICY THE PERSISTENT THEME OF BEHAVIOR THE WORLD’S EPIDEMIC

CHAPTER 7 - MANAGING THE IMAGINED EPIDEMIC

THE BIOTERRORISM SCARE HEALTH OFFICIALS AS SOOTHSAYERS THE OBESITY SCARE OBESITY AS FALL GUY FOR MODERN FEARS MANAGING MISGIVINGS ABOUT PARENTING: CHILDHOOD

OBESITY AUTISM, THE ADMINISTRATIVE EPIDEMIC

EPILOGUE

Acknowledgements NOTES SELECTED BIBLIOGRAPHY INDEX Copyright Page

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To my father

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INTRODUCTION TO THE PAPERBACK EDITION

A half-year after the hardcover publication of Dread, sleeves across America were being rolled up for the swine flu vaccine. New York City set out to inoculate schoolchildren, and pregnant women lined up to get vaccinated at their obstetricians’ offices. Although the swine flu outbreak had caused less harm in the six months since it started than almost any flu event of the past century, everyone was alarmed. And everyone had questions.

At a symposium in Holland, people asked me whether I thought their government really needed to buy up enough flu vaccine for every Dutch citizen. A reporter in Chicago told me he saw boycotts of soccer games involving Mexican teams, because people thought the flu could be spread by Mexicans. A Canadian radio host asked whether her country was worrying too much about the flu. An Australian physician and another in France chided me for my refusal to endorse the sky-is-falling rhetoric of flu preparedness. Around the U.S., hand-sanitizer dispensers flowered at supermarket checkouts, airport security points, libraries, and classrooms; colleagues and friends wondered whether the sanitizing gel could really stop the flu virus. At home in New York, nurses cried foul at mandatory immunizations (later rescinded). Physicians expressed frustration at the difficulty of persuading parents to have their kids immunized against flu. Parents everywhere were wary of exposing their child to yet another vaccine, and wondered if they were being sold a bill of goods by health officials. The Boston Globe reported that vaccine manufacturers were expecting to take in $7 billion from swine flu in 2009 alone.

A big threat—or just big hype? In the fall of 2009, no one could ignore the swine flu. It was in the headlines, a feature of television talk shows, the subject of conferences and official press releases, the theme for posters reminding us to wash our hands, the reason why some people donned masks on the subway and others refused to shake hands, the trigger for new policies in schools and colleges and, of course, the billions of taxpayer dollars, euros, and yen spent on vaccines.

Swine flu, or “H1N1 2009,” made the premise of this book seem prophetic. As an epidemiologist and compassionate observer, it’s impossible for me to be happy about a nasty disease outbreak responsible for thousands of deaths. As an author, though, it’s gratifying that the outbreak, and its attendant debates, so quickly proved the book’s point: that a society’s epidemic narrative reflects its own anxieties and dreads—not necessarily real harm or ensuing suffering.

From the beginning, both media and health officials depicted the flu outbreak of 2009 as a crisis. American newsmakers and media in particular had a decided influence on international news.

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The crisis began in April 2009, when brief reports of an unusual flu strain in California and Texas were followed by a summary article in the New York Times that effectively set the stage for pandemic worry. The first major news coverage, the Times’s article “Unusual Strain of Swine Flu Is Found in People in 2 States,” made several points that were crucial to shaping the pandemic narrative. The article hinted that a new strain of flu was afoot, that it came from Mexico, and that it had some of the characteristics of past pandemic strains. Although no link had been established between seven cases of flu in California and Texas and an outbreak of adult respiratory illness in Mexico, the article reported that Mexican authorities had noted a high death rate there—essentially creating an association in people’s minds. It reported that the new flu was made up of genetic elements “from North American swine, bird, and human flu strains as well as one from Eurasian swine.” And it pointed out that all the new cases were under the age of 55, lower than the usual age range for serious flu cases.

The next day’s Times story, “Fighting Deadly Flu, Mexico Shuts Schools,” explicitly linked the Mexican outbreak to the disastrous flu outbreak of 1918, which killed tens of millions of people worldwide in a matter of months. Measured in deaths per month, the Spanish Flu has never been equaled. When the Times piece pointed out that the young age of the 2009 flu victims was worrisome because “pandemic flus—like the 1918 Spanish Flu . . .—often strike young, healthy people the hardest,” alarm bells went off.

In the first two days of reporting, America’s premier newspaper had established the grammar for the story of a new pandemic: There was a new strain of influenza. It came from animals. It was causing a big outbreak in a country that, significantly for Americans, is not only poor but has long been suspected of exporting noxious influences northward—including drugs, the Spanish language, and undocumented immigrants. Its pathologic pattern was similar to that of the 1918 flu (and so was its origin in animals). As in 1918, schools were being closed. The story of global threat was being written, and read, widely.

As is so often true, the epidemic is a story of crisis. And a pandemic becomes a pandemic as the crisis story is recounted by the media. The New York Times’s flu coverage jumped in 2003. That year, the paper ran fifty articles on flu, mostly focusing on the threat posed by H5N1, the avian flu. In the following year, while the government in Washington shifted from bioterrorism preparedness to flu- pandemic preparedness (the White House had kicked off the bioterrorism preparedness fad with Project Bioshield in 2002, but issued a new pandemic plan focusing on flu in August 2004), flu coverage in the Times climbed to over ninety articles per year, where it remained for some time. The Washington Post showed a similar pattern, with flu coverage nearly tripling between 2002 and 2004 and continuing to rise thereafter. A Times reader would have encountered an article on flu roughly every six weeks before 1996; by 2006 she would see one every four days. A Post reader would have seen flu mentioned in the paper’s A section about once a week in 2002, but nearly once per day by 2006.

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But don’t blame the news media alone. They package the news on diseases as it is created by health officials, scientists, funding agencies, regulatory agencies, and others. It’s better to look at the account of swine-flu-as-global-threat as the Preparedness Crusade—a rhetorical campaign launched by a virtual industry whose product is health threats. Public health officials, agencies and foundations that provide monies for research, scientific and health researchers, industries that make products supposedly designed to protect against threats, and, yes, the media, all benefit when the public is alarmed.

For government agencies, an aim of the preparedness rhetoric has been to play on people’s ingrained sense of vulnerability in the modern world, and on putatively highlighted fears after the September 11 disasters. But this unease hardly began in 2001; it is a most unmodern feeling that can be traced back at least to the Middle Ages. It is the very reason why Christians of the Black Death era thought God had sent plague to punish impiousness, and why when cholera arrived in 1848 Americans held a national fast day to expiate what many saw as the faithless imprudence of a restless nation. The worry that our social arrangements invite disaster in ways that our forebears’ social arrangements did not—the sense that the good old days were safer and happier—always crystallizes when there is a threat of epidemic illness. We suspect we are receiving our just deserts. Those who want our affection, our dollars, or our votes have always been able to capitalize on that anxiety. The preparedness rhetoric, as promoted by the White House but endorsed by the industries of public health and medicine in America and, increasingly, abroad, evokes a frightening future. It asserts that only scientists and health officials can read its auguries correctly. And it demands that the public allow officials to state what is going to go wrong and what must be done to prevent that.

Forecasting a frightening future that’s manageable only by state officials is not purely an American habit. Although it was the director of the U.S. Centers for Disease Control and Prevention who forthrightly called swine flu “a major problem [that] requires a major response,” he was not alone. The Chinese government invoked special authority to restrict liberties in the name of staving off epidemics—and used it to quarantine foreigners visiting the country. British officials were criticized for failing to force widespread flu testing, and the U.K. health minister responded with an incautious (and fantastical) forecast of 100,000 new cases per day. Russia officially banned pork imports from the U.S. And Egypt’s regime set out to kill 300,000 pigs.

In early June 2009, the World Health Organization declared swine flu a pandemic. Dire scenarios involving widespread death and economic duress were predicted. In August, a White House scientific advisory committee predicted that flu might infect a third to a half of all Americans—up to 150 million people, that is —and lead to as many as 1.8 million hospitalizations and 90,000 deaths. Committee members defended their inclusion of such a horror scenario in their supposedly scientific report, claiming they were not predicting but merely attempting to examine scientifically the plausible upper edge of possible outcomes

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of the outbreak. But were they really shocked when the news media seized on their “scenario” as a certainty and broadcast the news that the president’s science advisors thought swine flu would kill 90,000 Americans?

The dire forecasts were useful to some people, though. Opinion makers and moral entrepreneurs had been issuing sky-is-falling warnings about flu for years, part of the new American industry devoted to creating health scares. Now, health professionals pointed to the new flu forecasts as if the mere suspicion of mass hospitalization and death—the “scenario” alone—verified the earlier predictions. For the business of health scare manufacturing, even a mild outbreak of flu can be engineered into the apparent fulfillment of wild expectations.

The expectations came from the preparedness campaign, much promoted by the World Health Organization and supported by statute in the U.S. The preparedness campaign insisted that a cataclysmic global influenza outbreak was bound to happen. It is comforting to think that public policy and planning are based on the observed facts of a disease—incidence, mortality, vaccine efficacy, rate of spread, and so forth. But with flu, expectations of future harm, not facts, drive the discussion. It is as if, once a future has been forecast, it is real and should be treated as real or, as many like to say, “scientific.” The facts of infection rate, vaccine effectiveness, and so forth, appear to validate the forecast—except when the facts debunk the forecast and de-claw the threat, in which case they’re ignored.

As of the end of 2009, about 12,000 people had died from confirmed swine flu infection worldwide. Even accounting for up to 36,000 additional deaths from other causes triggered by swine flu, the 2009 flu killed fewer people in the eight months after the outbreak began than diarrheal illnesses do in the world’s poor countries in any single month. Malaria, TB, and AIDS are likewise far deadlier than swine flu: together they are responsible for 5 million deaths a year, almost all of them in impoverished nations. Swine flu’s toll in 2009 was 100 times less.

But the clemency of flu by comparison to diarrhea, malaria, TB, or AIDS was not a fact deemed relevant in the response to swine flu. Nor was the fact that, in clinical trials, the best flu vaccines protect only about 70 percent of recipients against infection with influenza virus. Or that of the 147 children who died of flu in the U.S. between September ’08 and September ’09, 70 percent also had bacterial infections—suggesting that the problem might not have been flu per se but a failure of medical care to offer appropriate antibiotic treatment to those with severe cases of flu. The fact that antiviral medications like oseltamivir (Tamiflu) have never been shown to reduce the spread of influenza virus was not part of the discussion about distributing the drug; nor was the fact that the U.S. president had successfully pressed for authorization to purchase $1.7 billion worth of Tamiflu in 2005, or that the man who was U.S. secretary of defense at the time had held stock in a company (Gilead Sciences, which had held the original oseltamivir patent) that profited from Tamiflu sales, or that the appearance of swine flu in 2009 upped the purchase of Tamiflu worldwide to 200 million doses, representing additional profit

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for manufacturer Roche. The facts deemed relevant were the ones that supported the preparedness campaign and its parent industry, the one that creates health scares. As this book explains, this pattern is now common with health officials: calling an event an epidemic frees them from the burden of producing facts.

Only a short time after the swine flu outbreak, debate arose over the appropriation of the terms “epidemic” and “pandemic.” On June 11, 2009, the World Health Organization raised its so-called pandemic threat indicator to 6, the highest possible level. “Pandemic,” concocted out of “epidemic,” indicated an outbreak that affects the whole world, and WHO meant it that way. But the agency took flak from public health professionals who decried the delay in declaring a pandemic. At the same time, the agency was attacked by other health professionals who feared that WHO’s proposal that an outbreak’s severity (and not just its extent) should determine whether it was a global threat would dilute what they thought (erroneously) to be the purely scientific meaning of the term pandemic. Another group of commentators criticized WHO for creating such a hubbub over an outbreak that, after three months, was responsible for fewer deaths worldwide than occur in a single weekend on roads in the EU countries.

The debate over whether swine flu should be considered a pandemic, and the more circumscribed debates over whether schools should be closed, travel delayed, Tamiflu stockpiled, etcetera, tended to obscure some of the more compelling questions about flu and epidemics in general.

How much does the sense that swine flu is a global threat stem from its initial recognition in America, for instance? If there had been no flu fatalities in the U.S., would there have been so much demand for a “response” to this pandemic threat? What makes news in the United States, especially when the news is conveyed by the New York Times, Washington Post, or a few other core sources, is especially likely to be carried in non-U.S. news media.

Would people have demanded that WHO raise its pandemic threat barometer to the highest level if their sense of foreboding had not been whetted by years of the pandemic preparedness campaign, with its high price, high profile, and repeated reminders of the horrors of the 1918 flu? When the alleged bioterrorism threat turned out to be chimerical, the preparedness campaign that had manipulated America’s public into supporting endless war shifted to flu. That gave it a more global appeal. But it was still based on the idea of security. How would people have responded to the flu problem if public health, rather than preparedness, had been our watchword? Might we have decided that swine flu was a lesser concern than, say, automobile fatalities—a source of unremitting harm (over 30,000 Americans die in vehicle accidents each year, far more than swine flu claimed in 2009), which, unlike influenza, could really be abated permanently with public policy adjustments regarding public transportation, gasoline prices, urban planning, food industry regulation, and so on? Might we have decided that other

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global problems that don’t affect our own society as much—childhood diarrhea, malaria, or AIDS, for instance—really deserved more attention than swine flu?

Had there been no campaign to create flu fears, this mild outbreak surely would have carried less meaning. But “epidemic” is a loaded term. The discussions about an epidemic—and there have been many, with swine flu—are not really about the facts of illness or death; they are about the competition to impart meaning and convince others that one preferred meaning is correct.

In that sense, the swine flu experience brings to life the central message of this book: throughout history, the facts of harm have often been distant from the perceptions of threat, and the struggle to close the gap has given rise to assertions about risk. When we heed warnings about the supposed need to invest in more germ-fighting technology, when we buy the rhetoric that an epidemic illness must be confronted because of its alleged capacity to damage future generations, when we ignore the self-evident distress of others in order to attend to risk in our own people, or when we agree to give up liberties in exchange for protection from risk, we are acting in the modern version of an old drama, a story in which fears and anxieties are transformed into meaning—into the epidemic.

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INTRODUCTION

THE ORIGINS OF DREAD

Death in it self is nothing; but we fear To be we know not what, we know not where.

—JOHN DRYDEN, AURENG-ZEBE (1675)

Epidemics fascinate us. Look at all the ways we offer accounts of epidemics, and

how often. There are thousands of books in print about epidemics. There are histories of epidemics past, like the Black Death of the 1340s, the yellow fever outbreaks of 1793, cholera in the mid-1800s, the Spanish Flu pandemic of 1918, and polio in the mid-twentieth century. There are dozens of books reporting on today’s pandemic, AIDS. There are books about possible future epidemics, like avian flu. There are “what-if ” books about made-up epidemics sparked by bioterrorism. There are textbooks on epidemic malaria, SARS, dengue fever, encephalitis, HIV infection, and more. There are books about present-day epidemics of obesity, celiac disease, macular degeneration, hepatitis C, anxiety, asthma, attention-deficit/ hyperactivity disorder, autism, childhood bipolar disorders, restless-leg syndrome, mind-body disorders, anger, teen sex, inflammation, methamphetamine use, terror on the Internet, absentee and permissive parents, and “affluenza.” There are myriad fictional accounts of epidemics, including Defoe’s Journal of the Plague Year, Camus’s The Plague, Michael Crichton’s The Andromeda Strain, and Myla Goldberg’s Wickett’s Remedy. There are dozens of films (Outbreak, The Seventh Seal, 28 Days Later, Panic in the Streets, and more). The television programs, magazine articles, and Web sites on all aspects of epidemics are simply countless.

Yet amid the outpouring of words and images about epidemics, much remains hazy. There’s no constant, neatly defined thing that we can all agree is an epidemic. Nor do we agree on how to describe one. For Camus, a plague outbreak in an Algerian city reveals what is most human about its residents. In Tony Kushner’s Angels in America, the AIDS epidemic stands as a metaphor for the sickness within American society in the 1980s. An epidemic of a mysterious “leprosy” in Karel Čapek’s 1937 play The White Scourge is a straightforward

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allegory of ideology-driven imperialism. Cholera reflects the fevered erotic state of Aschenbach, the main character of “Death in Venice,” and the epidemic sets the stage for his demise as he yearns for an inaccessible love. These authors were not ignorant of the scientific findings on disease (by the time Mann wrote “Death in Venice,” in 1912, the Vibrio cholerae bacterium, which causes the disease, had been known for decades, and the means by which it is transmitted were well understood). When F. W. Murnau made Nosferatu, the first film version of Bram Stoker’s Dracula story, in 1922, the details of plague epidemics were well known. But Murnau made use of plague as a harrowing visual motif for the deadly havoc wrought by his film’s vampire, Count Orlock. At almost the same time as Murnau was filming the plague-carrying vampire rising out of a rat-infested ship’s hold to spread disease, public-health authorities were using scientific knowledge to curtail real plague epidemics in Paris and Los Angeles.

Perhaps these contrasts represent no more than instances of artistic license. Leave art aside, then. Our own reactions to illness and death reveal similar contrasts. More than 100,000 Americans die every year from unintentional injuries, including about 40,000 fatalities associated with motor-vehicle crashes. American teens and young adults are more likely to die from unintentional injuries than from any other cause; only homicide and suicide come close. Yet we don’t speak about an epidemic of accidents in the United States, beyond the conversation about automobile safety—and even when we do talk about vehicle mishaps, we rarely go beyond drunk driving. By contrast, there are seven- or eightfold fewer deaths from AIDS in the United States (about 14,000 annually). Still, AIDS provides grounds for continuing admonitions about the perils of drugs and sex, as well as discussions about health-care delivery, community awareness, and sex education. Pneumonia and kidney failure are far more common causes of death, and nobody talks about those as public-health crises. What accounts for the mismatch between the human costs of disease and popular rhetoric about epidemics?

One answer is that epidemics create opportunities to convey messages. The Progressive movement of the early 1900s used epidemics as a rationale to further its program of preventing venereal disease by reshaping sexual mores. The U.S. medical establishment leaned on the epidemic message about infantile paralysis— poliomyelitis—to enable it to finance and carry out a national effort to develop a polio vaccine in the mid-twentieth century. Parents of autistic children in Britain and America today put the epidemic of autism to work to demand that vaccines not be used. Pharmaceutical companies raise the specter of epidemic cervical cancer to promote the vaccine against human papillomavirus. The nature of the epidemic message is neither clear nor constant. Often, the message seems to have less to do with the actual disease burden or death toll than political opportunism. Or money.

Sometimes the lesson we are supposed to learn from an epidemic threat is not the result of any realistic assessment of dangers, but of maneuvering by the fastest claimant or most powerful bidder. What message did “epidemic” convey when, in

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2007, a man said to have “XDR” tuberculosis was arrested by federal authorities, removed from the hospital where he was in isolation, and made the subject of a press conference (and lawsuits) in the name of preventing an epidemic of TB— even though he was not infectious? What does “epidemic” signal when the World Health Organization announces that it sees a global threat in the epidemic of obesity—even though most of the people who are considered “overweight” or “obese” are less likely to die than are people who are very thin? What should we understand by “epidemic” when it is a label we can apply equally to the Black Death and restless-leg syndrome?

When officials or entrepreneurs make use of an epidemic threat to create politically or financially useful lessons, they follow a long tradition. Medieval Christians burned Jews in hopes of warding off epidemics of plague; outbreaks of cholera in the mid-nineteenth century were blamed on Irish immigrants in England and America; early-twentieth-century epidemics of plague in San Francisco and Los Angeles were said to be caused by immigrants (Chinese and Mexican, respectively); and venereal disease epidemics have been attributed historically to “loose women.”

A deeper answer to the question about why hype about epidemics doesn’t line up with the scale of damage has to do with fear. We humans dread death. It is only natural that the mass mortality brought by a great plague makes us afraid. And besides our dread of death, we are frightened by the prospect of social disruption. To live in civilized society is to bear a dread that goes beyond the fear of death.

Perhaps this is what we really mean when we call ourselves developed countries: we live in relative comfort for a comparatively long time (some more comfortably and longer than others, but even our poor are generally better off than most residents of the so-called developing world); we are fearful about losing this way of life. We of the developed nations seem to load epidemics with anxieties about death or the collapse of society. Sometimes we are right to be afraid of cataclysmic disease. The Black Death was a sudden catastrophe. Usually, though, nature is subtler.

The deeper answer, and the one this book explores, has to do with anxieties that go beyond the normal dread of death or destitution. To judge by our response to epidemics that are less sudden or catastrophic than the Black Death, we fear much more besides: strangers, flying things, modern technology, female sexual desire, racial difference, parenting, the food we eat, and so on. These concerns, beyond the simple dread of death, are part of our makeup. They identify us as citizens of the society we live in and distinguish our world from the ancient world of demons. The way we have responded to epidemics like polio, AIDS, and SARS, and the way we are currently responding to obesity, autism, and addiction, reveal that we bring fears to the prospect of any sort of epidemic, deadly or not.

This book looks at epidemics throughout Western history, going back to the Greeks and Romans, moving up through the Black Death and the development of

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epidemiology in the nineteenth century, and continuing to the present day. It looks at epidemics from three different perspectives. First, an epidemic registers as a physical event: there is a microbial disturbance in an ecosystem with accompanying shifts in the well-being of different human populations. An epidemic also plays a role in social crisis: the illness and death that spread widely act as destabilizers, disrupting the organization of classes, groups, and clans that make up the society we know. Finally, an epidemic has an identity as a narrative that knits its other aspects together: we tell ourselves stories about ourselves, accounts that make sense of what we see happening as well as what we fear (and hope) will happen. These three aspects of the epidemic can’t be divorced from one another: all significant spread of illness also creates a social phenomenon; every social crisis moves us to make sense of it; each revision of the story of our society alters the way we study disease (and even how we define illness) and changes the pitch of social change. To read the history of epidemics is to follow a long story of the fears that go beyond the dread of death, the anxieties that make us who we are.

Epidemics often start with an outbreak of disease, but not always—and not all disease outbreaks spark us to tell an epidemic story. The so-called Spanish Flu of 1918 was the most acutely devastating outbreak of all time, with upwards of 40 million deaths worldwide in barely a year. Camouflaged by World War I, or perhaps just too catastrophic to dwell on, the flu outbreak registered hardly at all in the Western imagination, at least to judge by the absence of mention in literature or art for decades afterward. Then, in the 1970s, it became not just an epidemic but a central element of the epidemic imagination when scientists who were interested in promoting their theory that devastating flu outbreaks occur every decade or so made the 1918 outbreak an object of historical interest. Today, all discussions of flu involve some retrospection on the Spanish Flu epidemic, the rationale for “pandemic preparedness.” There is an imagined epidemic that carries meanings not self-evident in the original event.

Some epidemics start without any disease being in evidence at all, as the creation of today’s obesity epidemic reveals. An epidemic is a story that has different morals for different “readers”: it teaches various lessons, follows differing accounts (depending on who is telling us what is happening), and can be a sounding of the alarm or a lament or an admonition. This book tells the story of epidemics—of how the way of looking at disease outbreaks affects what people see when there is one, and how, in turn, the epidemic we see changes how we act and what we fear. The story changes as society changes. As such, it has the capacity to illustrate the times in question and reveal the people themselves.

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CHAPTER 1

THE SENSE OF AN EPIDEMIC

And which of the gods was it that set them on to quarrel? It was the son of Jove and Leto; for he was

angry with the king and sent a pestilence upon the host to plague the people, because the son of

Atreus had dishonoured Chryses his priest. —HOMER, THE ILIAD, BOOK I

Seven years after an autumn 2001 epidemic of anthrax closed U.S. mail-sorting

facilities and killed five Americans, the FBI has its man. Or so the agency claims: the master bioterrorist who spread spores and a certain amount of havoc in the tense autumn of 2001 was, the Bureau now alleges, Bruce Ivins. He was a scientist who worked on biological weapons at a U.S. government installation (we must call this “biodefense” because if the U.S. government were researching offensive biological agents, it would be violating the 1972 international convention on biological weapons). We cannot know whether Ivins was the culprit: he killed himself in July 2008, just before the FBI made its case against him public. But by now it is obvious that the anthrax scare and the years of hysteria it provoked over biological mayhem engineered by foreigners was based on a chimera.

The Axis of Evil, so-called nonstate actors like Al Qaeda, out-of-work scientists from the former Soviet Union, other supposedly nefarious outsiders and historical enemies—none of these has had a role in creating American epidemics. Besides the postal anthrax event of 2001, in which twenty-two people became sick and five died, only one other epidemic can be plausibly attributed to biological weapons in North America, a smallpox outbreak among tribes of the Ohio Valley during the French and Indian War in 1763. Neither incident was the work of enemy fighters or religious zealots. If human invention produced the two epidemics, it seems to have been perfidy by government agents: in the first case, a British military officer’s “gift” of infected blankets to the tribes aligned with the enemy; in the recent one, a disgruntled scientist. The $20 billion that the United States has spent on protecting the public from epidemics created by human hands in the past decade might be

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pointless or might itself be putting people in danger, but in any case it has not solved an epidemic-by-bioterrorism problem, since such a problem never really existed.

The hysteria around anthrax began with an extraordinary welling up of dread. The September 11 disasters were a still-smoldering memory. The new gravity of life seemed to mute the customary talk of risk, as if organizing daily activities in order to maximize health (the low-fat diet, the buckled seat belt, the drinking of a single glass of red wine with dinner) had come to seem like self-indulgent effrontery in the face of the prospect of dying in a falling building, or as if health were simply in the hands of God or fate and not up to us. But when the bacterium Bacillus anthracis arrived by letter in October and people came down with anthrax, dread coalesced around the threat of an anthrax epidemic.

An industry fueled by fears of epidemics by bioterrorism existed before September 11, but it was little more than a start-up. Anthrax kicked it into high gear. As if to corroborate our fiercest anxieties, sci-fi scenarios were professed. In late October 2001, a symposium at Harvard’s School of Public Health featured estimable researchers and health officials lecturing on the possibility of crop dusters spraying pestilence. Admonitions about smallpox were heard. Pundits painted horrendous scenarios of cities wiped out by germs dropped from airplanes. Professor Walter Laqueur, chair of the International Research Council and a member of the Center for Strategic and International Studies in Washington, observed that “according to a 1980 study, spreading one ounce of anthrax spores . . . in a domed stadium could infect 60,000 to 80,000 people within an hour.” The state of horror was so poignantly highlighted by the new anthrax cases that, to some, such scenarios seemed prophetic.

The Centers for Disease Control and Prevention, the federal agency charged with protecting the American public from disease threats, was unable or unwilling to define how people were contracting anthrax, who would not contract it, or what could be done to render safe those venues in which infections had occurred. The CDC is usually prompt in investigating outbreaks, but it was hampered by the FBI in this case when the Bureau insisted that some information was classified because of an “ongoing criminal investigation.” Although much information was made public, almost none of it was usefully informative as to how little chance anyone ran of encountering anthrax spores, how nearly impossible it was to acquire anthrax from a person who had been infected, and how consequently minuscule the odds were that there would be a broad epidemic.

The anthrax outbreak of 2001 was an epidemic by the epidemiologist’s definition, but it was an unusual provocation for panic. To an epidemiologist, an epidemic exists whenever there are more cases of a disease in a specified place during a particular period than would be expected based on experience. Tuberculosis, with 9 million new cases each year worldwide and almost 2 million deaths, is not epidemic by this standard: its toll is great, but epidemiologists have

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learned to expect it. Ditto malaria, which kills three-quarters of a million African children each year. Because anthrax outbreaks are extremely rare, twenty-two cases in the eastern United States in a two-month period constituted an epidemic. But there was no person-to-person transmission, and in a world that has seen AIDS, TB, and malaria, it was hardly a public-health disaster.

“Epidemic” has always been a troubled term, shifting with humankind’s fears. The history of our encounters with epidemic disease is a story of people making sense of the extraordinary in terms of the ordinary. Some themes have been constant through recorded history: from malady in the ancient Middle Eastern land of Chaldea to the biblical plagues in Egypt to postal anthrax in the United States, the way we have thought about epidemics has involved ideas about place and disaster, two more-or-less concrete notions about the natural world, and a more elusive understanding of disease. For the past 2,500 years our understanding of disease has evolved with the state of knowledge about how we are affected by nature, and it has borne a changing burden of anxieties about bodies, souls, and the way we live in the world we have made. Prominently, ancient suspicions of contamination, divine punishment, and moral correction have permeated humanity’s awareness of disease and continue to influence our grasp of the epidemic.

The modern use of the word “epidemic” to describe diseases was introduced by Hippocrates, the early Greek medical writer, who lived around 400 BC. In Part Three of his canonical work, On Airs, Waters, and Places, Hippocrates drew the first distinction between epidemic and endemic conditions:

Pleurisies, peri-pneumonias, ardent fevers, and whatever diseases are reckoned acute, do not often occur, for such diseases are not apt to prevail where the bowels are loose. Ophthalmias occur of a humid character, but not of a serious nature, and of short duration, unless they attack epidemically from the change of the seasons. And when they pass their fiftieth year, defluxions supervening from the brain, render them paralytic when exposed suddenly to strokes of the sun, or to cold. These diseases are endemic to them, and, moreover, if any epidemic disease connected with the change of the seasons, prevail, they are also liable to it.

Hippocrates is celebrated by modern physicians as the father of medicine, but the significance of Hippocratic thought is neglected by almost everyone else— most lamentably by epidemiologists and other social scientists. His philosophical project was revolutionary; we owe the very essence of public health to it. For centuries before Hippocrates’ time, Greeks had been attributing disease to the gods. In proposing that illness comes from elements that can be observed in the

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real world, not the acts of inscrutable deities, Hippocrates was both amending a traditional viewpoint and reconfiguring the basic idea of disease. His views weakened the influence exerted by human beings’ inchoate dread of the unknown, positioning disease as a piece of the puzzle of nature—a puzzle with rules, or at least logic, that mere humans could assess. By loosening the grip of innate dread of the unknown, Hippocrates opened the door to investing disease with fears and hopes grounded in the known world.

Hippocrates did not invent the word “epidemic.” It predated him by centuries. Derived from the Greek word for people or populace (demos), epidemiou (επιδημιου) in ancient times meant to be in, or come to, one’s people: a modern English approximation might be “having to do with being at home” or “toward home.” In The Iliad, Homer refers to civil war as polemos epidemios. The meaning evolved, and “epidemic” eventually came to mean something like “indigenous” or “native.”

Hippocrates used “epidemic” exactly in the “native” sense, applying it to illness as part of his project to take disease out of the hands of the gods. The Hippocratic theory of illness was that each place had characteristic diseases. Some diseases could be related to particular environments, such as the seaside, marshes, mountains, and so forth, and therefore were prone to establish themselves in certain places. They were “epidemic” in the sense that they were native, like the epidemic ophthalmias (inflammations of the eye) in the passage above. Hippocrates denoted as “endemic” diseases related to the “fluxes,” or internal fluids, whose nature therefore corresponded to individuals, not places. Hippocrates’ distinction between epidemic and endemic was not, as modern public-health textbooks claim, based on an early observation that diseases that strike occasionally but in intense episodes (epidemic) differ from those that are ever present (endemic). That was a much later development, which required a more modern consciousness.

Nor did Hippocrates connect epidemic disease to contagion. The clustering of disease was interesting to Hippocrates, since the accumulation of cases in relation to demonstrable elements of terrain and climate served his theory. For instance, he noted that what appear to be the well-known tertian and quartan fevers (those that come with a three- and four-day periodicity) of malaria occurred in proximity to marshy regions, even though two millenniums would go by before it would be known that malaria is spread by mosquitoes. His descriptions also seem to point to other recognizable conditions, such as dysentery and diphtheria. But the transmission of disease in the Hippocratic model had to do with fluxes, not invisible contagious particles.

The Greeks had inherited ancient ideas of malady as an effusion of the underworld and translated them into specific diseases resulting from explicit actions of the gods. Hippocrates’ theories broke with theology. Hippocrates made illness empirical.

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In Homer’s day, pestilence was understood as an act of the gods. The disease that decimates the Achaean army at the beginning of The Iliad is ignited by a flaming arrow shot by the god Apollo (the son of Jove by Leto), who is angry with the Achaean leader, Agamémnon, for his treatment of the priest Khrysês. Attributing to the gods the power to strike people ill or dead in retribution for improper acts, the ancient Greeks tried to make sense of illness and gave disease a moral meaning as well as a physical one.

The idea of pestilence as punishment lost its power with the Greeks, to be revived much later with Christianity. But even before Hippocrates’ work was widely known, Greeks were moving away from the assumption that the gods were angry when pestilence struck. The historian Thucydides, roughly a contemporary of Hippocrates, saw no particular godly reprisal in the Plague of Athens of 427 BC. Writing circa 410 BC, he says:

[The Peloponnesians and their allies] had not yet spent many days in Attica when the disease [nosos] first struck the Athenians. It is said to have broken out previously in many other places, in the region of Lemnos and elsewhere, but there was no previous record of so great a pestilence [loimos] and destruction of human life.

Making an explicit connection between disease and pestilence, Thucydides nonetheless offers only a speculation about its provenance:

The plague is said to have come first of all from Ethiopia beyond Egypt; and from there it fell on Egypt and Libya and on much of the King’s land. It struck the city of Athens suddenly. People in [the Athenian port city of] Piraeus caught it first, and so, since there were not yet any fountains there, they actually alleged that the Peloponnesians had put poison in the wells.

Thucydides’ observation effectively hammers home the intensity of the plague by pointing out that it was too awesome and unprecedented to allow for theories about cause: “All speculation as to its origin and its causes, if causes can be found adequate to produce so great a disturbance, I leave to other writers.” He had freed himself of the old Homeric certainties that the gods must be behind an extraordinary event. But the ordinary provided no clues as to why such a catastrophe would occur.

Pestilence remained a malleable term. Sometime before 29 BC, in the Georgics, Virgil invokes the word “pestilence” (pestis in Latin) when he reports on an outbreak of disease among cattle, pecudum pestes, in the Alpine regions north of the Adriatic. An agrarian treatise rather than a work of history, the Georgics had a practical outlook: to describe bad things that could happen to livestock if they were

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not managed properly. Virgil’s text explicitly states that pestilence can be wholesale: “Not single victims do diseases seize, but a whole summer’s fold in one stroke.” But he also used “pestilence” metaphorically to indicate a scourge, a bothersome thing—like the adder he calls pestis acerba boum, the “sore plague” of cattle, capable of gliding under the straw that shelters the herd and harming cows with its venom. Pestis could point to something dire without implying what we would call an epidemic.

The distinction between “pestilence” and “plague” becomes crucial. The first implies uncertain origins without connoting punishment, while the second implies intent. From pestis came the French word peste and the German Pest, as well as the English word “pestilence.” Peste and Pest denote a cataclysmic outbreak of disease. But in English the development was different: over time, the Latin word for delivering a blow, plagare, “to strike” (from the Doric Greek plaga [πλαγα], meaning “stroke” or “wound”), became the English word “plague.” The same word, not accidentally, became the modern medical name for the disease caused by the bacterium Yersinia pestis, the organism that was responsible for the Black Death. Whereas German, French, and other languages that use a word derived from pestis to mean “plague” reflect the Virgilian era, the English “plague” connects words associated with punishment (strike, blow) inseparably to the idea of disastrous disease outbreaks.

The connection between plague and epidemics traces to the story of Exodus in the Bible. The disasters delivered by God to the Egyptians were punishing blows. According to the text, the blows were meant to achieve an end: to get the Egyptians to free the Hebrews from slavery. The fifth plague in Exodus was livestock illness (the Hebrew is dever, meaning, like the Greek loimos, “pestilence”). That this catastrophe became not just pestilence but a plague reveals how much we need to recognize the divine intent behind the pestilence as well as the dire outcome.

Early Hebrew philosophy contributed to the understanding of epidemic disease in a different manner from that of the Greeks, and profoundly. Ancient Hebrew writing might seem to have pioneered the concept of plague as a divine blow, but Mesopotamian texts, already ancient by the time the Five Books of Moses were written down, had long before attributed disease to the work of demons. Reshaping disease around contamination was Hebrew philosophy’s lasting contribution to how we see epidemics.

As with Hippocratic philosophy, Hebrew thinking was jarringly different from the traditional suspicions about possession or enchantment by dark spirits. Malaise

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(spiritual and therefore physical) was now the result of the specific work of a single, all-powerful God rather than various demons. But more important, malady resulted from the imprudent mingling of the pure with the impure. The Greeks also explained ailments as the intentional work of Apollo or other gods in response to human behavior rather than the unknowable whims of fickle demons and spirits. Where the Hebrews’ way of thinking differed was that by focusing on contamination or pollution, judgments about disease became empirical.

By 500 BC, warnings against contamination passed along through oral tradition had been collected into what became the biblical book of Leviticus. There, the connections are made clear: crossing from fair to foul taints the spirit, and spiritual pollution fouls the physical body. Leviticus 7:19 reads: “The flesh that touches any contaminated thing may not be eaten.” To the Hebrews, pestilence wasn’t a sign of the mystifying fickleness of the spirit world but a divine work by a wrathful God insistent that humans do right. “If you behave casually with me and refuse to heed me, then I shall lay a further blow upon you. I will send a pestilence among you and you will be delivered into the hand of your enemy” (Lev. 26:21-26). Pestilence could be visited as punishment just as easily on the community as it could on the individual. In II Samuel (24:10-15), King David is given a choice of three punishments because of his pridefulness: seven years of famine for his people, three months fleeing from his enemies, or three days of plague in the land. Depending on the translation, David either chooses pestilence or merely chooses not to have to flee his enemies—but in all versions, God sends the plague. David survives, but 77,000 people die. The Hebrews thereby linked pestilential disaster to transgression and emphasized collective responsibility and shared fate. In so far as disease outbreaks come to be distinguished from other disasters, this biblical scenario, like the visitation inflicted on the Achaean host in The Iliad, offered an early example of disease as punishment.

The conjunction of ritual, right behavior, avoidance of divine wrath, and health is nowhere clearer than in the laws of the kashrut, detailed rules for eating and cooking that appear in chapter 11 of Leviticus and that are still followed by some observant Jews. Designating spiritually unclean and clean animals, the kashrut essentially divided the natural world based on contamination. Eating any animal that does not both have a cleft hoof and chew its cud is strictly forbidden. About twenty species of birds are unclean, among them those that famously serve as metaphors of evil in Western culture: vultures, kites, and ravens. Lizards and snakes are prohibited, too.

The Levitical laws on spiritual unease made three things clear that are important to understanding how people have come to see disease: spiritual taint has physical manifestations, it can arise without human awareness, and it can be redressed through the individual’s efforts. If a person was struck by an ailment that was the consequence of contamination, it could, according to the Levitical law, be cured. Leviticus probably spends more words on a manifestation of spiritual unease, tzara’as, than on any other. Tzara’at referred to a set of three possible physical

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signs of a particular spiritual malaise. The three lesions were s’eit, sapachat, and baheret—each a different type of discolored skin. Tzara’at was described as visual evidence that the sufferer had committed one of a set of spiritual offenses: robbery, slander, false oaths, sexual misconduct, bloodshed, or selfishness. Some rabbis have suggested tzara’at represented God’s punishment for a particular set of deeds, those revealing a failure to share the feelings or recognize the needs of others.

The biblical text gives complex instructions for how a priest might determine if a skin lesion was indeed evidence of tzara’at and how to handle a contaminated person. There is, famously, the command (Lev. 13:46) that the metzora, the contaminated person, dwell “outside the camp”—that he be ostracized, kept from association with the spiritually sound. And there are instructions as to how, after a suitable period of isolation whose tribulations will remind the metzora of the seriousness of falling off the spiritual wagon, the priests can purify him and return him to the circle of society.

Such were the ancient foundations of the modern concept of epidemic disease. Physical ailments, even if inseparable from spiritual malaise, emerged from the realm of mystery and enchantment and came to have causes that were accessible to the properly informed person. A person could avoid spiritual taint through scrupulous, self-aware control of his or her interactions with nature—in other words, humans could thrive in a universe whose underlying logic was observable in physical signs. The logic could be answered with rules, laws, limits, or codes. The instinctive human dread of chaos or the unknown could be redirected into specific fears that misbehavior, contamination, or transgression of well-defined limits would bring harm.

At some point, the word “epidemic” appeared in Latin (epidemia) as a way to designate a disease outbreak. “Epidemic” was carried into Middle French (ypidimie) and eventually appeared in English, making its premiere in 1472, when Sir John Paston wrote that many of the English soldiers who went to fight in Brittany died of the “flluxe or other ipedemye.” The progression in thought and naming was primarily a result of the tremendous outbreak of disease caused by Y. pestis—plague, to us—that produced astonishing and still unparalleled carnage in Europe between 1347 and 1351.

By the fourteenth century, physical disease was distinct from mental or behavioral aberrations. Diagnostic capabilities were good enough by then that physicians could be sure that these repeated visitations were manifestations of the same disease. To the survivors of those plague outbreaks, a sudden and widespread

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occurrence of a physical ailment wasn’t a metaphor; it had quite concrete meaning. Exactly when the term “epidemic” came to be applied to the plague outbreaks isn’t known, but it is clear enough that by Paston’s day, everyone would have known exactly what he meant by “the flux or other epidemics.”

The thinking about epidemics in that day could not be disentangled from the inchoate dread of death or randomness that had influenced the ancients, and the occurrences of plague in the fourteenth and fifteenth centuries, beginning with the first wave of the Black Death, in 1347, were still surrounded by mystery. Yet a fixed set of ideas emerged from them: disease was an identifiable, physical thing. Big outbreaks of disease had a recognizable progression in time, with a beginning, a middle, and an end. Ailments that came and went in the population (outbreak diseases, we would say today) were distinguishable from those that seemed to be around all the time, like consumption, “dropsie,” “rising in the guts,” or death in childbirth.

By about 1600, with plague outbreaks still a frequent occurrence in Western Europe, the defining story of the modern epidemic took full shape. By then, an epidemic was presumed to have a physical cause, not to be the meddlesome work of evil spirits or the sudden anger of a god (although the anger of the Christian God was still an important part of the story for some people). By the seventeenth century, bodily illness had become distinct from mental or spiritual maladies. Epidemics were illnesses of humans, verifiably different from animal diseases. An epidemic of common physical disorder was distinct in its origins from other events bringing widespread unhappiness, like flood or drought. And it was assumed that, eventually, the epidemic would end.

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CHAPTER 2

PLAGUE: BIRTH OF THE MODEL EPIDEMIC

There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise.

—ALBERT CAMUS, THE PLAGUE

Plague in fourteenth-century Europe has long been the model for the epidemic.

Even as humankind accumulates knowledge about coping with disastrous epidemics and becomes more self-assured about defying nature, we return to the antique memory of the Black Death. When illness threatens society, envisaging an epidemic in the form of the Black Death allows us to discharge many fears.

So it was that in the late summer of 1982, media stories reminded Americans of a link between AIDS and homosexuality with blunt and brutally insensitive headlines announcing the “gay plague.” That unforgettable epithet announced our society’s anxieties while commenting on American sexual politics. Pundits who spoke of the new plague as divine punishment for homosexual intercourse explicitly evoked apocalyptic scenarios.

When alarmist media used the word “plague” about AIDS, they clearly alluded to the Black Death. So does anyone who uses “plague” today. The Black Death was the greatest disease outbreak in Western history. Most historians agree that it killed at least a quarter, possibly more, of the population of Europe between 1347 and 1351—perhaps 25 million people. The Black Death was the archetypal epidemic.

Aside from being an efficient killer, plague was a cataclysm on which people piled meanings: treachery, foreignness, sanctity and faithlessness, dying for one’s religion, obeying (or rebelling against) authority, and, of course, the fecklessness of nature. It acquired more layers of metaphor over time, none of which is exactly about epidemics, or even disease. We like to think that we see epidemic disease objectively today—rationally, and with a science-infused awareness. But it’s debatable whether we have significantly revised our thinking since the first year of the Black Death.

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In the 1980s AIDS seemed, literally, fabulous; it was reported as if it were a tale from Aesop or the Brothers Grimm. Hardly anyone questioned that the new disease was imbued with a moral. It was called a plague. Whenever we refer to something as a “plague,” we mean that it is subtler than we can detect, bigger than we can imagine, a battle that we ought to be fighting but are not, or one that we are fighting but do not know it. Sometimes we mean that a threat is afoot that is capable of destroying our civilization. Or we simply signal that people ought to take things more seriously. Plague was not only significant historically as a shaping force in European civic life. It remains important in the lasting effects it has had on speech and action in the public realm.

During the plague era in Europe, which lasted from that first devastating outbreak in the mid-1300s until about 1700 (later in some parts of the continent), the template by which we interpret facts about disease outbreaks as validating our preconceived fears was forged. At the same time, public health as we know it today became a mainstay of the capacity of the state to guide the lives of its citizens.

Plague is caused by the bacterium Yersinia pestis. The bacterium infects rodents (rats and ground squirrels, mostly) and lagomorphs (rabbits and hares), as well as other small mammals. It enters these animals by the bite of a flea—most commonly, Xenopsylla cheopis, the Oriental rat flea (the species was discovered in Egypt in 1903; its name comes from Cheops, the pharaoh believed to have built the Great Pyramid at Giza).

If there are plague bacteria in an animal’s bloodstream, a flea will suck them up into its stomach during feeding, after which the bacteria reproduce within the flea’s digestive tract. When the flea jumps to a new animal to feed, it is unable to take in blood because the multiplying Y. pestis bacteria clog its feeding tube; it bites frantically, and eventually it regurgitates bacteria into the animal’s bloodstream, thereby transmitting the plague organism. When rats or other hosts are unavailable, hungry fleas bite humans who happen to live around rodents and their fleas.1

For the most part, humans contract plague only through the bite of fleas that carry the bacterium. This was true even during the spread of the Black Death in medieval Europe. Once infected, humans rarely transmit the plague bacillus to other humans.2 In the days before antibiotic treatment, most people who contracted plague died of it.3 Isolated plague cases continue to occur every year, mostly through contact with wild rodents, but they are easily treated with common antibiotics. Continuous chains of transmission from person to person, or rat to

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person to rat to person, are rare. Substantial outbreaks occur today only in crowded conditions under unusual circumstances. For instance, an unusually forceful earthquake in September 1993 reportedly destroyed a million homes and led to a plague outbreak centered in the Indian state of Sura that resulted in several hundred cases.

A plague epidemic is not simply an illness gone out of control: it is a natural event, one that involves many changes in the environment and whose effects resonate throughout ecosystems. A sudden outbreak of any serious disease among humans is rare. It happens only when the circumstances are aligned just so, when an improbable conjunction of climate, diet, human social arrangements, animal and insect population dynamics, and the natural movements of germs happens to occur. In effect, an epidemic is a kind of complicated accident.

THE COMING OF PLAGUE TO EUROPE

The Justinian Plague, whose first wave swept through the Mediterranean trading ports in the years 541-544, struck a region that was largely still under the sway of the Byzantine Empire (the pandemic was named after Emperor Justinian, who reigned from 529 to 565). The sixth-century historian Procopius reported its symptoms, fever and buboes in the groin and armpit followed by delirium and death within days. Plague returned beginning in the 570s and reached Rome in 589 (it was lifted the following year, according to legend, when Pope Gregory had a vision of the archangel Michael looming over the tomb of Hadrian). Subsequent salients poked as far inland as Lyon and Tours and recurred, occasionally, for two centuries. The last outbreaks occurred in the 760s.

Thereafter, no chronicler mentioned plague in Europe for almost six hundred years. When plague returned to Western Europe, it came from central Asia, passing through Constantinople, then the Sicilian port of Messina in 1347. It was able to spread through a society with newly populous cities interconnected by trade.

The reach of plague in the sixth, seventh, and eighth centuries had been constrained by the long duration of overland journeys. The incubation period of pneumonic plague (the only form that would allow for flea-free, person-to-person transmission) is very short, sometimes as little as a day, and the pneumonic form is so fatal that few plague-sick travelers on a journey of any length would have lived to infect business contacts or acquaintances in a new port of call. Overland commerce in the early Middle Ages did not involve the movement of masses of rats, as trade later would (especially once seagoing commerce in the Mediterranean connected with large caravans coming through the Near East). If animals accompanying caravans were infected with Y. pestis, they would likely have died before arrival, so the outbreak could not move very fast.

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Europe in the mid-fourteenth century was dramatically different from what it had been in the 700s. Increased crop yields during the thirteenth century allowed for an expansion of rat populations, which would have increased the potential for animal outbreaks of plague. And the social changes that came with the waning of feudalism in the thirteenth and fourteenth centuries added to the climate changes to exert effects on humans, rats, and fleas that bumped the region out of quiescence. Some twentieth-century authors claim that the European plague epidemic began in China in 1330-1340; others put the origin in central Asia—roughly in the area north and west of India, today’s Afghanistan-Turkmenistan-Uzbekistan region. Probably, plague had occurred in the central Asian high plains in the form of seasonal outbreaks for centuries before the fourteenth, flaring up when wild rodents that were carriers of the bacillus emerged from their burrows at the end of each rainy season. Nosopsylla fasciatus, the Northern rat flea, and other fleas that could live on rats both in the wild and in human habitations would have moved plague from its usual countryside cycle into the towns. The local rats of Asian trading centers would have carried plague-transmitting fleas to the rodents that moved with the caravans. The expansion of trade after the Crusades, linking Europe and central Asia via the Near East, created a virtual flea bridge.

In particular, trade routes linking commercial centers provided a network by which rats could migrate long distances and intermix with local animal populations. By the 1300s, European ports like Marseilles, Genoa, Naples, and Messina were well connected to central Asia via trading centers in the Near East, such as Smyrna, Constantinople (now Istanbul), and Kaffa (Feodosiya). The peripatetic rat population aboard Mediterranean and Black Sea trading ships would have come in contact with animals on central Asian caravans and picked up fleas from feral Asian rodents. Wild rodents in the high country leading up to the Himalayas were especially important, because plague might have circulated at high levels among wild mammals there.

Once in densely populated Europe, plague moved fairly quickly from town to town. It was probably the closeness of settlements, rather than the now-higher density of populations within Europe’s fourteenth-century cities, that set the stage for the fast expansion of plague after 1347. When human settlements were isolated but not too far apart, the number of rats per human would have been high in rural dorps or isolated households. The rat-flea-human-flea-rat cycle would have spread the plague bacillus rapidly within such locales, creating sudden explosions of human plague in the countryside. Frequent travel between the no-longer-isolated rural settlements and the now-larger cities in turn helped spread plague from villages where plague was expanding rapidly but where there were few humans for it to infect to the cities, where it could spread widely among both rats and humans.

Plague’s spread across the land in the 1340s was fast, but outbreaks extended erratically. After appearing in Sicily in 1347, plague had affected both Barcelona and Rome by May 1348 and Paris by June of that year—but Strasbourg, only about 250 miles from Paris, was not stricken until eight months later, in February 1349.

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Plague broke out in Mainz in August 1349 but not until 1350 in Rotterdam (only 212 miles away, and itself a seaport). In each place, the outbreak lasted for a year or less, although in some northern climates plague vanished for the winter but returned with warmer weather. The wave of outbreaks moved roughly clockwise along the seacoasts, from the Mediterranean northward, and from the coasts inland, then gradually eastward: the regions that are now Italy, southern France, and Spain were affected in 1348; northern France, England, southern Germany, and Austria in 1349; northern Germany and Scotland in 1350; Poland and the Baltic area in 1351; Moscow and environs in 1352. By the time it was over the population was drastically reduced almost everywhere in Europe: by the mid-1400s, after a century of plague, population had fallen by two-thirds. There were food shortages for want of labor to bring in the harvest.

Yet in its day the question of the Black Death’s point of origin was not urgent. On the whole, fourteenth- and fifteenth-century chroniclers, prelates, and officials were more concerned with how plague spread and what could be done about it. In particular, European authors writing during or shortly after the first wave of plague wondered whether it was the work of God or Satan. “This is an example of the wonderful deeds and power of God,” wrote ibn Khatimah in Andalusia, Spain. In Ireland, John Clyn of the Friars Minor felt the world to be “placed within the grasp of the Evil One.” The communicability of plague was unquestioned in its own time, although the particular mode of communication—be it contagion, intemperate air, poisoned water, or astrological influence—was a matter of disagreement.

Pinpointing cause is a more modern concern. As plague is spread by the bite of a flea that has been feeding on an infected rat, it is the bacillus-transmitting flea bite that we now think of as plague’s cause. Similarly, we say that tuberculosis is caused and spread by an airborne bacterium, carried in a droplet of sputum from a cough. We no longer wonder about devilry or divine works. Today it is risk we seek to uncover and predict. And by predicting, we engage in an illusion that we curtail our risk. In the fourteenth century, devilry, rather than risk, was the threat posed by outbreaks of plague.

DISEASE AND FEARS OF CONSPIRACY

To a medieval Christian, physical illness was indistinguishable from spiritual failing, and spiritual failing was the work of malign forces. The disbeliever invited the devil in. Therefore, the punishment embodied in illness might be a just desert for a failure of faith. Although the reason any individual merited the scourging wreaked by physical illness might not be self-evident, it was assumed that sickness was an expression of divine punishment for ill faith. Not yet obliged to look for causes of disease in the physical world, as we do today, Christians of the fourteenth

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century could see spiritual malaise behind any aberration of the body. Since physical illness was spiritual, and spiritual malaise was a flame that had to be tamped down lest it ignite a blaze of faithlessness, it was a duty of medieval Christians to prevent illness’s spread. (It wasn’t until much later, when physical and spiritual welfare were seen as separate, that people would decide that illness has a definable, earthly, and observable cause.)

Controlling disease, or at least curtailing the movements of spiritual distempers, required that medieval Christians act collectively. Community action taken to control the spread of plague would become public health as we know it today. At its beginnings, the motives for communal action were both practical and spiritual. An emotional tide of dread, propelled by anxiety about devilry, led people to monitor physical illness as evidence of spiritual malaise. Along with constructive actions aimed at preventing the spread of ill faith by interrupting the advance of physical disease, such anxieties about devilry led to gruesome exterminations, particularly of Jews. The fourteenth-century Jew hunt that occurred at the height of the Black Death prefigured the Holocaust of the twentieth century and crudely illustrated how self-protection from real physical threats and dread of spiritual contamination were often knitted together in the attempt to understand plague.

For centuries before plague, fears that the bedeviled might conspire to undermine Christian society led to the exclusion of the leper—who might be anyone who was suspected, by reason of appearance or behavior, of spiritual taint. Medieval Christians interpreted very strictly the injunction in Leviticus 13:45-46 against consorting with lepers. “Being impure,” the biblical text reads, the leper “shall dwell apart; his dwelling shall be outside the camp.”

According to historian Sheldon Watts, when medieval Europeans followed the instructions of the Levitical text to ostracize lepers, they misidentified the disease in question. The spiritual affliction with which chapter 13 of Leviticus is entirely concerned, tzara’at, was not modern-day Hansen’s disease (a bacterial illness).4 The implication in Leviticus of barring the afflicted metzora from full participation in society was not that a physical illness made its sufferers unfit to be part of society. It was that the individual was expected to undertake spiritual reform. But medieval Christians, reading the Latin version of Leviticus, thought that they were called upon to exile people with the disease “leprosy,” i.e., Hansen’s disease.

By misapplying Leviticus’s injunction about moral taint to a physical condition, medieval Christians essentially created the leper. Something essential was lost in translation. After the Council of Lyon of 583, lepers were forbidden to associate with healthy people, and laws regulating interactions with lepers were established. By the twelfth century or so, a long list of characteristics could cause a person to be labeled a leper—from various skin disorders to behavior that signaled trouble to policy makers or the church. Unlike tzara’at, medieval leprosy was not redressed by a period of segregation and contemplation. Leprosy was permanent.

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Lazarettos, hostels for lepers, existed in Europe from the seventh or eighth century, but it wasn’t until the Third Lateran Council, in 1179, that all lepers were required to wear identifying insignia and towns had to maintain lazarettos to house and feed them. Once a specific prescription for dealing with lepers was in place, a Christian could demonstrate his moral uprightness by giving succor to the leper. In this way, lepers were useful to the operation of Christian society: they were scorned but cared for, and they served as a touch-stone by which the faithful could reassure themselves of their piety.

In medieval society, people who were disdained because they had a disfiguring disease (or were merely imagined to represent a threat) could exist only by living apart. In this regard, the ostracizing of the leper foreshadowed the epidemic in the modern imagination. We no longer banish the carriers of spiritual taint, identifying them by disfigurement or skin ailments. But we do identify suspicious people by skin color, national origin, or sexual practice today as potentially infectious. Certainly, that was the point of proposals early in the U.S. AIDS outbreak to tattoo homosexual men and the reason for the drop in patronage at Chinese restaurants in U.S. cities when the severe adult respiratory syndrome (SARS) was spreading in Asia. We do not refer to them as such, but lepers still exist in the modern imagination.

PLAGUE AND VIOLENCE TOWARD JEWS

In medieval Europe, lepers and Jews were linked in the fearful minds of many Christians. Jews, as unbelievers, were inherently “leprous.” By 1215, Jews as well as lepers were ordered to wear clothing to indicate their status, so that Christians who were pure could avoid inadvertent contamination.

Like lepers, Jews might be bedeviled. But Jews were not fallen Christians, as lepers were. Nor were Jews heretics, who might seduce believers away from the “true faith” with an alternative vision of worship or different manner of obedience to God’s will. Jews were suspect, but they were also valuable. Jews lent money, which made them the object of envy, scorn, and resentment. Jews prepared food differently—which might have contributed to accusations that they poisoned Christian food and drink, used human blood in rituals, or desecrated the Host. Jews were also disproportionately represented among physicians in medieval society. It might have been easy to imagine that physicians knew how to tinker with food and drink. Doctors in those days, recommending powders and poultices, must frequently have poisoned their patients inadvertently, even though their sincere intentions were to cure. Physicians were well paid and well dressed, too, which must have added resentment to suspicions cast on Jewish doctors. In a society fearful of the devil’s enchantments, Jews were the cause of distress.

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By the fourteenth century, fear of diabolical conspiracy largely had shifted from lepers to Jews. In 1320, the Pastoureaux, peasant youth and children rising up against the authority of the crown in France, targeted Jews, whom they saw as protégés of the monarchy. The French king demanded that Jews be protected. Yet the Pastoureaux, along with local helpers, are said to have slaughtered every Jew in southern France.

In the wake of the Pastoureaux rebellion, King Philip V of France visited Poitou in the Aquitaine in 1321, where he was told that wells and springs had been infected with poisons by a great number of lepers (in times of distress, well poisoning had a specific resonance with the Bible: in the Apocalypse, as prophesied in Revelation 8:1-13, after the opening of the Seventh Seal a third of the earth’s waters would be poisoned by the fallen star Wormwood). By the account of the fourteenth-century chronicler Guillaume de Nangis, lepers were tried for poisoning the waters throughout the region, and confessions were extracted by torture or amid the flames while the lépreux were being burned at the stake. Lepers were forced to confess that their aim was to kill Christians or spread taint so as to turn the healthy leprous.

According to Guillaume, a nobleman at Parthenay wrote to King Philip that one of the important lepers had confessed that a rich Jew had encouraged him to commit the crime of well poisoning, paying him ten pounds, with the promise of more, if he would persuade other lepers to do the same. Jews, it was further understood, had convened the principal lepers for the purposes of interventions by the devil. “Care of the Jews, the fatal poisons were spread by lepers through the entire kingdom of France,” Guillaume wrote.

Secular authorities, who had previously supervised the maintenance of lepers and defended Jews from attacks, began to contribute to violence against both. In June 1321, King Philip issued an edict against lepers, followed in July by one against Jews.

When plague arrived in the region, a generation later, it served to crystallize fears of diabolical corruption. As plague advanced and rumors of its origin were connected to Jewish knowledge of poisons and conspiracy to undo Christian society, a series of attacks left Western Europe nearly devoid of Jews.

The violence against Jews began in Toulon, France, on Palm Sunday of 1348. Just as plague arrived there, townspeople assaulted the Jewish quarter, killing forty people. Violence against Jews during Easter week was not unusual in that era, but subsequent events made clear that the attacks of 1348 were a direct response to fears of the advancing wave of plague mortality. Attacks on Jews continued in Avignon and Grasse later that April, and spread to other towns in Provence and then Catalonia. Assaults on Jews continued through parts of Spain, the Savoy, the Vaud, the Black Forest, Bavaria (Munich, Nuremberg, Augsburg, Regensburg), Baden-Württemberg, and then the Rhineland, before moving east. Jews were accused of well poisoning, the indictment commonly leveled against suspected

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enchanters. With no experience of plague in human memory in the region and no focused concept of disease as the result of real-world causes, fear that the onset of plague was evidence of spiritual contamination likely motivated some of the attackers. But if so, their base fears let them be manipulated by leaders who planned to use plague for their own ends.

In Basel, mobs burned several hundred Jews in January 1349. In Strasbourg, the guilds deposed the ruling city council when it refused to persecute Jews, and elected a more compliant one. The Bürgermeister of Strasbourg pled for reason, but in February 1349, before plague had even reached the city, inhabitants burned the city’s Jews at stakes posted in the cemetery. In March, the Jews of Worms, in the Rhineland, immolated themselves inside their houses rather than fall into the hands of the mob. In the German city of Mainz, 12,000 Jews were burned to death. By July 1349 the pogroms had reached Cologne. The last slaughters were in Antwerp and Brussels in December of that year; all the Jews of those cities were killed. Within three years of the arrival of plague in Europe, Jews had been exterminated in or hounded out of hundreds of towns and cities.

These events were not, or at least not all, spontaneous outbursts. In the case of Nuremberg, Regensburg, and Frankfurt, the Holy Roman Emperor, Charles IV, had guaranteed ahead of time that the mobs could attack Jews with impunity. In Dresden, the Duke of Meissen instructed the townspeople to attack Jews in early 1349 and promised that there would be no sanctions brought against them for doing so. Presumably, those who most believed that the outbreak expressed God’s punishment, i.e., the devout poor, were easily persuaded to attack Jewish scapegoats. Meanwhile, the burghers, secular office-holders, and petty ecclesiastical officials could profit by taking over the property and valuables that Jews abandoned when they fled or died.

In some cases, there were judicial prosecutions against Jews, a sign that the attacks were not just the work of mobs aroused by private dread. In September 1348, a Jewish surgeon named Balavigny was interrogated by officials at Chillon, in Switzerland, until he was forced to “confess” that he had put into the water supply some powder that he had obtained from a “Rabbi Jacob” of Spain (a country where plague was already abroad). The Strassburg Urkundenbuch, the city of Strasbourg’s compilation of documents, contains detail from the time on the poisons that Jews supposedly used to create plague.

The church never sought to suppress Jewry or implicate Jews in the spread of plague at the time. On the contrary, Pope Clement VI issued two edicts, in July and September of 1348, prohibiting killing and forcible conversion of Jews. He admonished Christians not to attribute plague to the Jews, accusing anyone who did so of having been seduced by the devil. As evidence that Jews were not culpable, Clement noted that Jews were themselves affected by plague. The outbreak, he contended, was the result of a “mysterious decree of God.” If there

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was a civil conflict, then, it was between one mystery and another: God’s alleged will on the one side; Jews and a recondite conspiracy on the other.

The specific charges leveled against Jews when plague loomed were recapitulations of old accusations, particularly suspicions of intentional poisoning. But the sense that poisoners threatened society had its own practical power, too: poisoning was a persistent possibility at a time when food wasn’t always safe to eat; clean water might easily be contaminated by local industry; and physicians worked with apothecaries to provide patients with poultices, infusions, or electuaries (powders mixed with honey or sweet syrup) that were not fully systematized, let alone regulated. Medicines in that day were compounded of material from plants and animals or metallic substances, and treatments might have included applying plasters of dung or fumigating bedrooms with burning herbs. Chaucer, writing at the time, reminds us that fourteenth-century physicians were known to collude with apothecaries, the first prescribing medicines and the second producing them—not necessarily to the benefit of the patient but to the profit of both:

Ful redy hadde he his apothecaries To sende hym drogges and his letuaries,

For ech of hem made oother for to wynne. With plague and poisoning commonplace, it must have been easy for people to think of the death-filled days of the Black Death as a fulfillment of the nightmare vision of Apocalypse. The sense that doom was at hand was most likely fed by a pronounced trepidation about change. Some historians believe that the militant Christianity that had held European society in thrall during the early Crusades, the so-called Civitas Dei, or State of God, was relaxing its hold during the century and a half before plague arrived. Certainly, with the expansion of commerce in the thirteenth century came the rise of a middle class—still affixed to the church but no longer well served by the traditional institutions of medieval Christianity. One reason for the violence against Jews might be that plague offered an excuse to take over Jewish wealth and property—a lynchpin of social tension in the thirteenth and fourteenth centuries. Had it been Christian belief alone that drove the mobs, Pope Clement’s injunction would have persuaded them to desist.

It’s impossible to know whether most people thought Jews had much to do with real problems of contracting disease or dying. By the time the plague’s frontier had reached into northern Germany, Eastern Europe, and Scotland, the extermination of Jews was over—not because the epidemic had moved on but because the holocaust had largely succeeded in its fundamental goal: surviving Jews had either converted or moved out of the region. Attacks on Jews didn’t end permanently when the plague moved to the northern and eastern regions; in the 1380s and ’90s, Jews in Halle, Durkheim, and Colmar, again suspected of having poisoned wells, were attacked. Jews were expelled from Cologne in 1424 on this basis, and in 1488 a plague outbreak in Saxony was attributed to the arrival from Nuremberg of a

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converted Jew. So the holocaust of 1348-1349 can only have ended because the flames ran out of fuel. It might well have continued had there been Jews left to target.

Western Europe froze into deep, troubled sleep in the 1340s. The Apocalypse seemed to show itself as reports of plague and its devastation arrived, horror deepening as deaths from plague and fire piled up. There was deep-felt dread about disappearance, the imminent end of the world, and the sudden, terrible collapse featured in Revelation. Long-harbored fears about conspiracy and contamination came to focus on lepers and then on Jews (and eventually on witches). The intensity of the mortality that plague wrought was new, but the responses it elicited were, in a sense, all old news.

With Apocalypse in mind and the dread of occult evils brought out by massive disease outbreaks, plague and penitence became inseparable. Plague offered an opportunity to confess sins and seek forgiveness. Pope Gregory had articulated the connection between plague and penitence during the Justinian plague, in the sixth century. As related by his contemporary Gregory of Tours, Pope Gregory reminded the faithful in 591 that “all the people are smitten by the sword of divine wrath; one after another they are swept away by sudden death. . . . The blow falls; the victim is snatched away before he can . . . repent. . . . Let every one of us therefore betake himself to lamentation and repentance before the blow has fallen.” If pestilence is an act of God, and if the people can learn from it that the fruits of sin are disease and death, then the victims of plague give their lives for others’ holy benefit.

Plague’s links to sin, punishment, and salvation also became common motifs in visual art. Plague in art could be a signal of the End of Days, the primitive condition from which mortal beings could (and were expected to) lift themselves through faith, or a divine pestilence from which a city could be lifted by the intercession of a saint.

The Jesuits knew that plague could elicit repentance, and they expanded on the themes of sin and forgiveness. In the sixteenth century, some Jesuits claimed that plagues were sent expressly to purge evil and reward good. One, Guy Rouillet, called the plague outbreak in Ferrara, Italy, in 1558 an emblem of God’s punishment, delivered because of divine love. Another, Everard Mercurian, wrote in 1564 that God had sent the peste to Tournai in order to heal its inhabitants’ spiritual pestilence. The Jesuit Dominique Mengin expressed his gratitude for plague in Munich in 1562 because it turned the city’s residents away from the “pleasures of this world and delights of the flesh” and toward divine sacrament.

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This wasn’t just a Jesuit conceit; the archbishop of Cologne ordered a three-day fast and the displaying of holy relics in order to combat the plague outbreak of 1564.

To a degree, pestilence is still the context for confession. Basketball star Magic Johnson, acknowledging that he had become infected with the AIDS virus through sex, advised abstinence. Another well-known HIV-infected man, Larry Kramer, novelist, playwright, and AIDS activist, said that “we [gay men] are murdering each other. . . . I know I murdered some of them.” Compared with the confessions of the time of Justinian, the modern penitent’s admissions of misbehavior might be driven less by eagerness to get into heaven and more by a desire to help others through public repentance (perhaps to create a laudable public image, too). But they are confessions that would not have resounded had it not been for epidemic disease.

ILLNESS AND FAITH

Europeans’ experiences throughout the period of plague outbreaks shaped the imagination of disease—and linked it to Christian faith. Depictions of plague in paintings and engravings were a kind of visual prayer, a reminder of faith. The viewer could come back to images of plague-ridden cities as she or he would come back, each day or week, to a church or a Bible reading. Disease, suffering, the lamentation of the bereaved, the vain attempts of pitiable infants to suckle at their dead mothers’ breasts, the scourge of plague—all were wrapped, visually, in acts or failures of faith.

The relief of plague through acts of faith or divine love was illustrated from early on. The Limbourg brothers depicted Pope Gregory’s vision of St. Michael, which reputedly lifted plague from Rome in 590, in the Belles Heures of the Duke de Berry in 1410, and again a few years later in the Très Riches Heures (see figure 1). A 1456 painting by Giovanni di Paolo, St. Nicholas Saving Florence, shows the eponymous saint hovering over a depopulated city while the remaining residents enact religious rites related to plague (processionals, prayer, a funeral). In Luca Giordano’s Saint Gennaro Frees Naples from the Plague (1662), the saint hovers over a ghastly urban landscape littered with corpses, beseeching Jesus’ favor. Some of the bodies show telltale buboes and others the lacerations of surgeons’ fruitless attempts to save them. Faith, we are meant to understand, will save the city where earthly intervention failed.

Some plague art suggested that salvation was unattainable through holy intercession or reminded the viewer that plague was punishment. The Piazza Mercatello During the Plague of 1656, painted by Micco Spadaro (Domenico Gargiulo), shows a scene of Naples (the Piazza Mercatello is present-day Piazza Dante) where officials direct the cleanup of a corpse-littered landscape while the

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plague-stricken, dying in agony, look on (see figure 2). Gargiulo was a health deputy in Naples and must have witnessed the effects of the very outbreak that he took as his theme.

To view artwork that confirmed the connection between suffering and faith was itself a form of piety. There might be no better example of the vital power with which viewing was imbued in the plague days than Matthias Grünewald’s Isenheim Altarpiece (see figure 3). The work was commissioned by the monastic Order of St. Anthony in Isenheim in 1505 and completed between 1512 and 1516. Grünewald created it during the period when Martin Luther, lecturing at the University of Wittenberg on the centrality of salvation through faith in God, spurred the skepticism about church practices that became the Protestant Reformation. The piece is not explicitly about plague, although St. Sebastian, who is often associated with plague, appears next to a panel showing Christ crucified. Grünewald’s ostensible subject was the life, death, and entombment of Christ, but the piece had much to do with both salvation through faith and the appreciation of epidemic disease in that day.

Grünewald’s altarpiece is important evidence of how physical illness was understood at the end of the Middle Ages. Illness was always pertinent to the Antonine monks. The order had been established in Europe in 1095 and named for St. Anthony of Egypt, who was said to be able to cure the illness called ergotism, or St. Anthony’s fire. Ergotism results from eating cereals, especially rye, that are contaminated by the fungus Claviceps purpurea. It was a fairly common condition in medieval Europe. Its skin manifestations—gangrene can be one—made it distinctive at the time and led to an association with leprosy. Although the Antonines remained dedicated to curing ergotism in the Middle Ages, they were also known for the treatment of other illnesses, especially those that also caused swelling of the skin or desquamation. Thus, other conditions that would have come to the Antonine monks’ attention likely included shingles, leprosy, and plague.

At Isenheim, the monks brought the sick to see Grünewald’s altarpiece. The art historian Horst Ziermann makes a cogent case that the work was intended to be viewed by illiterate people, “the poorest of the poor,” and thus would have been observed not from left to right, as readers instinctively do, but in the opposite direction. Meant to elicit both compassion and feelings of guilt as ways to deepen the viewer’s piety, the right-to-left viewing would have taken in St. Anthony first, then the Crucifixion with Christ in obvious torment, and finally St. Sebastian pierced by arrows and draped in the brick-red cloth of martyrdom. The leftward movement of the gaze, through suffering to martyrdom and eventually to the open window, with its view of angels, was meant to engage the viewer’s subconscious in pious, compassionate contemplation. It reminded the sick that their sufferings were small compared with those of Jesus and told them not only that the promise of healing was extended by St. Anthony but also that it could be read in Jesus’ life. Observation was observance. The act of viewing salvation through acts of faith itself became a healing act of faith.

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Gradually, as plague outbreaks became irregular events in Europe, plague shed some of its mystical overlay. The line between magic and medicine was still thin and easily crossed—tokens and amulets supposed to ward off disease-carrying spirits were worn well into the sixteenth century, for instance. But from the late 1500s onward, physicians made practical recommendations for preventing plague, including perfuming clothing and carrying rue, angelica, madderwort, valerian, and other herbs. In 1665 the Royal College of Physicians 5 published recipes that might be of use to plague-afflicted Londoners. Among many remedies offered for use internally or, in some cases, topically were instructions to drink the Plague-water of Mathias; to take Mithridates’ medicine of figs or a conserve of red roses, wood sorrel, lovage, and sage; and to take a Plague-water compounded of rue, rosemary, sage, sorrel, celandine, and mugwort, with brambles, balm, and other plants, steeped in white wine.

Further promoting practical responses to plague, physicians of the seventeenth century connected private cleansing with public works. The Royal College of Physicians recommended that public gatherings be banned and streets kept clean. Perhaps the repeated rounds of plague outbreaks made it obvious that everyone’s chances of survival would be better if all agreed to certain collective measures.

New thinking about the possibilities for controlling plague did not displace religious devotion, but by the seventeenth century the role of the divine shared place with collective responsibility in shaping human fate. When Francis Herring of London published a monograph with rules for “This Time of Pestilentiall [sic] Contagion,” he called the outbreak a “stroke of God’s wrath for the sinnes of Mankinde” but also advised authorities to provide for the poor to keep them from vagabondage and to clean the streets. In Catalonia, the tanner Miquel Parets recorded both pious and practical responses to plague. Barcelona had banned trade with Tortosa, then afflicted with plague, in 1649, Parets noted. The arrival of plague in January 1651 prompted the Barcelona authorities to quarantine households struck by plague, burn the clothing of the affected, and fumigate entire streets. By April of that year, with plague continuing to spread, Parets wrote, the church had ordered that the relic of St. Severus be carried along the processional route because “our Lord was as angered with us.”

Europeans of the seventeenth century might still have been enthralled by visions of apocalypse and seduced by the possibility of salvation, but many had come to observe, make connections, figure, and act in practical ways. Thinking about epidemic disease became part of public thinking.

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PLAGUE AND THE GROWTH OF THE STATE

It wasn’t until the early eighteenth century that the countries of Western Europe had a real public, in the sense that there was a realm of human affairs that represented the nonprivate doings of the many: reacting to administrative decisions by the rulers, thinking about having the state do more (or less) policing of activities in the community, exchanging news about market prices or travel conditions. But the institutions that would contribute to the evolving public nature of civil society were shaped, in no small part, by plague.

The public aspects of plague began slowly but early on, with simple measures to prevent the movement of contagion. Quarantine, the isolation of potentially infective people or cargoes, might have been used in some form or other for many years even before the Black Death, but once plague arrived it was quickly institutionalized. In March 1348, plague having settled into Venice, the doge and his council began requiring that incoming ships lie offshore for a period of weeks before entering the city proper. For a time, the duration of the holding period varied. But by 1374 it was set at forty days at Venice and subsidiary ports, based on biblical accounts giving weight to forty-day periods, such as the Flood and Christ’s temptation in the wilderness. The forty-day period became customary, although it was never universal.

Venetian quarantine regulations were duplicated at Ragusa (now Dubrovnik), which belonged to Venice at the time, and adopted by Marseille in the 1480s. Later, other ports in the region followed suit. Inland cities also moved quickly to implement plague policies. Wrapping a controlled border around a town created a cordon sanitaire , first enacted by the Italian city of Pistoia in May 1348. Citizens of Pistoia and its contado, the adjoining countryside, were forbidden to travel to or from plague-stricken Pisa or Lucca except by special permission of the city’s elders, while people from Pisa and Lucca were banned from Pistoia.

Eventually, use of the quarantine and cordon sanitaire became standard around Europe. Along the Kaisersgrenze, the militarized boundary separating the Austro- Hungarian Empire from the Turks and Slavs to the east, travelers crossing the Pestkordon from east to west after 1770 could be interned in barracks for weeks, depending on their point of origin. Goods were stored and sometimes treated with chemicals or fumigated before being released for westward transport. By providing a sense of protection against the ingress of disease, the cordon sanitaire contributed to people’s sense of identity as a community, town, or nation. The inspection of travelers and goods became a mainstay of the idea of the national boundary, and it remains that today.

Wherever plague focused attention on aspects of the public arena, plague regulations were promulgated to accompany quarantines and cordons. By 1374, Milan had enacted laws requiring that anyone with a swelling or tumor be expelled from Milanese lands. Venice also excluded its plague sufferers, ferrying them out