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Learning from the black death
  1. John Launer
  1. Associate Editor, Postgraduate Medical Journal, London, UK
  1. Correspondence to Dr John Launer, Associate Editor, Postgraduate Medical Journal, London, UK; johnlauner{at}

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In the space of three or 4 years in the fourteenth century, around half the population of Europe died of plague. So did around a third of people in the Middle East and North Africa, as well as countless victims in central Asia – where the pandemic originated – and in China. Total deaths were probably around 75 million, only exceeded in history by the Second World War. Because the population of the world in the Middle Ages was far smaller than now, this meant that there was a direct impact on almost every town, village and family.1 For comparison, the current pandemic of COVID-19 has so far claimed around a tenth as many lives and has killed approximately one in a thousand of the world’s population, as opposed to nearly half. Our world is very different from seven centuries ago in terms of medical understanding, prevention and treatment but, as I will describe later, some aspects of the two events are strikingly similar. These include a range of human responses from heroism and well-informed management of spread to profiteering, rampant superstition and fake news.

In its time, the mediaeval pandemic was known simply as the Great Death. It was the second major outbreak of the disease, the first having occurred under the Byzantine Emperor Justinian in the sixth century. It was followed by lesser but devastating recurrences into modern times. (The most recent notified outbreak has been in the Democratic Republic of the Congo in April 2022.)2 Although a few scholars have argued that the Black Death may have been caused by a virus similar to Ebola, there seems little serious doubt that the responsible organism was the plague bacterium Yersinia pestis, named after the Swiss physician Alexandre Yersin from the Insitut Pasteur, who identified it in Hong Kong in 1894. Reservoirs of the organism are present in rodents, and the culprit in the case of plague was almost certainly a species of marmot native to central Asia called the tarbagan. Although plague can possibly pass direct from tarbagans to humans (just as SARS-CoV-2 may have come to us from pangolins), two intermediate species played far more important parts in the chain of transmission. One was the ubiquitous and prolific black rat, which may have acquired it from its marmot cousins. The other was the rat flea Xenopsylla cheopis, which prefers to suck rat blood but will bite people when especially hungry. The human flea Pulex irritans may then have aided spread between people.

Recent archaeological, historical and genomic data has shown that the first human victims of the Black Death almost certainly lived around Lake Issyk-Kul in modern Kyrgyzstan3 Between 1347 and 1351, a combination of circumstances facilitated the spread of plague from there to all four points of the compass, with devastating rapidity. As with COVID-19, global travel and trade were a crucial factor. Ships unwittingly carried a lethal freight of Genovese traders, grain, rats, fleas and Y pestis from the ports of the eastern Black Sea and Crimea towards Constantinople and Italy. Against a pre-existing background of poor nutrition, appalling hygiene, and in some places famine and warfare, the plague then travelled both by sea and land across the nations from Iran to Ireland and the Sahara to Sweden.

Rapid transmission

Clinically, plague took two forms. Bubonic plaque showed itself as buboes, or massively swollen lymph glands, leading to septicaemia or in some cases purulent abscesses which could burst. By contrast, infiltration of the lungs led to pneumonic plague with violent frothy haemoptysis. Death by either form was hideous and could occur within days or even hours, but pneumonic plague led to far more rapid transmission of the bacteria via droplets, obviating the need for rats or fleas as vectors. There are records of physicians and those in holy orders who sacrificed their lives to give succour to the dying. Some others, along with several rulers and many instant entrepreneurs, used the opportunity to steal, rape, extort and abandon their own families. The majority of these probably delayed their own deaths only for a short while, although as with COVID-19, the poor and old were more likely to die than the young and rich. Some cities like Venice implemented rigorous public health policies that included the systematic collection and disposal of corpses. In Farnham in southern England, a conscientious estate manager called John Ronewyk maintained agricultural production and the collection of rents on the local bishop’s land while half the population around him died. Elsewhere across three continents, some communities collapsed into anarchy or vanished completely.

It is impossible to relate emotionally to the deaths of hundreds or thousands of people at a time all within sight of each other, or to the annihilation of whole villages or half a city, so one man’s testimony must stand in here for all the surviving ones and those that were never written down. It comes from the chronicle of Agnolo di Tura, a merchant in Siena:

In many parts of Siena, very wide trenches were made, and in these they placed the bodies, throwing them in and covering them with but a little dirt. After that they put in the trench many other bodies and covered them also with earth and so they laid them layer upon layer, until the trench was full…Some of the dead were so ill covered that the dogs dragged them firth and devoured many bodies throughout the city. And I, Agnolo di Tura…buried my wife and five children with my own hands.1

End of days

Such testimonies, and the history books where these appear, convey the heart-rending personal impact of the Black Death on individuals. However, the most gripping portrayal of its effects on the minds, beliefs and philosophical outlook of the Middle Ages appears in a remarkable movie: ‘The Seventh Seal’ by the famous Swedish director Ingmar Bergman.4 Often listed among the greatest films of all time, it was made in the shadow of the Second World War and of Auschwitz and Hiroshima. It depicts the journey of a knight and his servant companion when they return from fighting in the Holy Land to find their native country overrun by the plague. Early on in the movie, Death appears as a personified figure wearing a black cape and challenges the knight to a game of chess, which then continues episodically throughout the plot – an idea inspired by a mediaeval church painting (see figure 1). By presenting Death’s implacable certainty that he will win the contest, the knight’s existential longing to find God, his servant’s black humour, and the dispositions of the characters they encounter – from chilling criminality to unshakeable optimism – Bergman manages to illustrate an entire gamut of human reactions to extremity and the perception that they are approaching the Apocalypse or End of Days.

Figure 1

Death playing chess, by Albertus Pictor (Sweden, 15th century).

For understandable reasons, the movie underplays some of the gruesome realities of plague including the mode of death itself, but it shows two historical features of the Black Death almost unflinchingly. One of these is the expression of religious guilt that swept across nations, with pious Christians joining in processions where they flagellated themselves and each other bloodily, in a bid for expiation and salvation. Even more excruciating, the movie shows the murderous persecution of individuals and groups believed to have brought death on the local populace through their imagined crimes or sins. In historical reality, this led to the burning alive of thousands of Jews who were accused of poisoning wells with the causative agent of plague. Presumably because of his own contemporary context, Bergman showed this allegorically with a scene that was commoner in later times: the burning at the stake of a teenage girl who has confessed to being a witch and having sex with the devil.

It is no surprise that few of the characters in ‘The Seventh Seal’ survive, but in one of the subtlest moments in the movie – so much so that you may miss it if you blink – the knight manages to distract Death during the final move in their chess game. While he does so, we see a family in the background making their escape in a horse drawn wagon. They are a couple of itinerant theatrical players and their toddler, whom they hope to train as a performer of miraculous skill. Later, they watch Death leading off all their companions in a ‘danse macabre’ on the horizon. The final image of Bergman’s masterpiece, showing those who died and a young family of survivors, captures both the horror of the Black Death and the continuance of hope beyond it.

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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