"BLIND CHANCE OR DIVINE RETRIBUTION

"BLIND CHANCE OR DIVINE RETRIBUTION?"

ROBERT K. STRONG

CHICAGO LITERARY CLUB

MARCH 1, 2004

In the year 1348 a disease we now call the Black Death raged through Italy. In Florence the historian Giovanni Villani considered the devastation around him and wrote a question in his chronicle of events: was this the result of blind chance or was it divine retribution? Today we would pose Villani's question somewhat differently, but the experience of the Black Death in late medieval Europe still resonates in our own age. Human society has been smart enough or lucky enough to avoid a global pandemic on the scale of the Black Death for almost a century. However, the emergence of AIDS and other alarming new infectious diseases make the events that Villani and others recorded in the fourteenth century worth reviewing.

At the time the disease was called the Great Mortality or simply the Pestilence, although centuries later it came to be called the Black Death. In the year 1347 it entered the Mediterranean basin, and in 1348 it conquered the Italian peninsula and spread through most of Spain and France. By 1351, it had run its course in a great arc through England, Germany, Scandinavia, and eastward into Russia. Mortality rates of 25% to 50% were commonly experienced in affected populations. The disease struck again in the 1360s and 1370s, in places as severely as the first epidemic, and it came back two or three times every generation for then next 150 years. It is believed that within 70 years of its first outbreak more than half of all Europeans died. For unknown reasons, a few areas such as Poland and Bohemia were less affected. But in most of Europe it was a disaster beyond the limits of imagination.

Around the year 1340 reports of natural disasters in the Far East first reached Europe. Italian merchants controlled European trade with the East from their trading posts on the Mediterranean and the Black Sea, and the disquieting news probably reached them through the long caravan and sea-borne trade routes from China and India. In 1346 an anonymous Flemish cleric wrote in the Chronicle of Flanders of news he received from a friend in the papal curia in Avignon: "In the East, hard by Greater India…horrors and unheard of tempest overwhelmed the whole province for the space of three days. On the first day there was a rain of frogs, serpents, lizards, scorpions, and many venomous beasts…. On the second,…lightning and sheets of fire fell upon the earth, mingled with hail stones of marvelous size, which slew almost all, from the greatest even to the least. On the third day there fell fire from heaven and stinking smoke, which slew all that were left of men and beasts…." There were other frightening reports of atmospheric disruptions and earthquakes, comets trailing poisonous gas, and invading swarms of locusts, rats, and snakes.

That these reports were taken seriously illustrates the nature of truth in the fourteenth century. Truth was not understood as factual accuracy but rather as consistency with authoritative texts. Truth was to be found in literary sources, not by direct observation of the natural world. The stories from the East were believable because they were consistent with stories in the Bible, especially the accounts in Exodus of natural disasters inflicted on the Egyptians by an angry God: frogs, flies, storms, hail, and locusts. Atmospheric disturbances, earthquakes, and noxious fumes from within the earth were also mentioned in ancient Greek and Persian texts considered authoritative. We now know from Chinese chronicles that several waves of epidemic disease swept through China in the 1330s inflicting high rates of mortality. One chronicle of 1353 states that two-thirds of China's population had died since 1331. But medieval Europe knew nothing of these factual details.

Europeans first encountered the Black Death in the town of Caffa on the Crimean Peninsula. There in 1346 merchants from the city of Genoa were besieged by a Mongol lord named Janibeg. "But behold," wrote the Italian chronicler Gabriele de' Mussis, "the whole (Tartar) army was affected by a disease which overran (them)…and killed thousands upon thousands every day….. The dying Tartars, stunned and stupefied by the immensity of the disaster,…ordered corpses to be (catapulted) into (the city) in the hope that the intolerable stench would kill everyone inside. What seemed like mountains of dead were thrown into the city, and the Christians could not hide…from them…." Whether or not this medieval use of a biological weapon of mass destruction is fact or fable, the Genoese were infected by the Black Death in Caffa. They fled in their ships back to Italy, stopping at Messina, the principle port of Sicily, in October 1347. Despite the fleet's quick departure on orders from civic authorities, the Black Death spread throughout Sicily. By December 1347 it crossed the Mediterranean to the ports and fishing villages of Italy and southern France and began its deadly march through Europe.

During the 12 months of 1348 the Black Death spread from the Mediterranean coast throughout Italy, Spain, France, Switzerland, and into southern England and southern Germany. Mortality records are scattered and imprecise, but the evidence suggests that within a very short time -- perhaps three months -- of its arrival in a town or region the Black Death killed massive numbers of people: 30% of the populations in Genoa and Pisa; 40% in Prato, Pistoia, and Venice; 50% in Florence, Orvieto, and Siena. Rural areas appear to have suffered mortality rates around 30%.

The individual chronicles from different Italian cities tell the story on a smaller scale. Gabrielle de' Mussis of Piacenza wrote, "In the spring of 1348 (a) Genoese infected with the pestilence came…(and) almost immediately afterwards he died…. In a brief (time)…the pestilence was rife throughout the city…. Everywhere there was weeping and mourning. So great was the mortality that men hardly dared breathe. The dead were without number, and those who still lived gave themselves up for lost and prepared for the tomb…." The Florentine writer Giovanni Boccaccio reported that coffins frequently had two or three corpses in them from the same family. "And very often it happened," he wrote, "that two priests, each with a cross, would be on their way to bury someone, when porters carrying three or four (more coffins) would…follow along (just) behind them; and (while) these priests thought they had (only) one dead man to bury, they had, in fact, six or eight and sometimes more. Moreover, the dead were honored with no tears or candles or funeral mourners …. So many corpses would arrive in front of a church…that the amount of holy ground for burials was…insufficient for the ancient custom of giving each body its individual place. Huge trenches were dug…and into them…new arrivals were dumped by the hundreds. They were packed in…with dirt, one on top of another, like a ship's cargo, until the trench was filled." Later it would become impossible to find a priest or a grave. Agnolo di Tura wrote in Siena that "it was a cruel and terrible thing," barely possible "for the human tongue to recount…. None could be found to bury the dead for money or friendship. Members of a household brought their dead to a ditch as best they could, without priest, without divine offices." To Agnolo di Tura, who buried his five children with his own hands, it appeared to be the end of the world.

Why had the pestilence come? The Church saw parallels between the Black Death and biblical precedent: when God grows angry, He punishes mankind with widespread suffering. The chronicler Gabriele de' Mussis stated a fanciful version of the widely-held belief: "…Almighty God, king of heaven…looked down…and saw the entire human race wallowing in the mire of wickedness,…(and He) called out to the earth 'why do you not demand human blood in vengeance for this wrongdoing?'… And the earth replied, 'I…shall open and swallow up the countless criminals…."

The Church encouraged the view that God's displeasure with human wickedness was the cause of the Black Death. Writers and sermons put forth a catalogue of sins requiring acts of penance, going beyond the seven deadly sins to include such contemporary evils as dishonest judges and lawyers; cheating merchants; lechery and hypocrisy in the clergy; indecent clothing; disobedient children; and the display of women's fashions at tournaments. Christians were instructed to repent and return to the path of righteousness. Some cities attacked sin directly by issuing ordinances forbidding the manufacture or use of dice; prohibiting the "usual swearing by God or the saints"; and ordering all men with a concubine to "either marry her or put her away…."(

Charitable donations to the Church were encouraged as a means of assuring salvation, and many death-bed gifts of land and money were received from wealthy sinners anxious to die in the good graces of the Almighty. In England a quarter of all estates under will went to the Church during the Black Death, and donations to religious institutions in France were 50% higher than a generation earlier. Pilgrimage was another popular act of the faithful, and wills in England and Italy show a significant rise in bequests to pilgrims. Travel guidebooks were written telling pilgrims where they should stop to eat or spend the night, and the city of Venice even went so far as to offer what might be called a "package tour," complete with safe conduct passes and arranged housing.

A new and extreme form of penance was practiced by a religious movement know as the flagellants, which arose spontaneously in northern Europe in the belief that extreme punishment of the flesh was required to appease God. Jean de Venette, an observer, wrote that "while the pestilence was still active and spreading from town to town, men in Germany and (the Low Countries) arose and began a new sect on their own authority. Stripped to the waist, they…marched in procession through the…towns. They formed circles and beat upon their backs with (whips)…, rejoicing as they did so in loud voices…." The chronicle of Henry of Hervordia reports that each whip had three knotted thongs, each knot containing two sharp pieces of metal arranged in the form of a cross. "Using these whips," Henry wrote, "they beat…their bare skin until…blood rained down spattering the walls nearby." The flagellants were wildly popular with common people caught up in the spectacle of blood and suffering, but the movement arose outside the Church and was not officially sanctioned. Fearing that such rites undermined its religious authority and sensing a rebuke to clerical inadequacy, the Church suppressed the flagellants.

Closely associated with the flagellants was persecution of the Jews. In southern France Jews were accused of causing the pestilence by poisoning wells, and after confessions extracted by torture Jews were murdered and their property seized. Further confessions under torture in Switzerland resulted in the massacre of entire Jewish communities by mobs with the support of civil authorities. The slaughter spread quickly from Switzerland north to Germany, spurred on there by the flagellants. The Pope granted his protection to Jewish communities and, on threat of excommunication, decreed that Christians should not shed Jewish blood without trial. But the murders continued, including those of Christians who tried to protect their Jewish friends. The chronicle of Herman Gigas records that "God… has not suffered the malice of the Jews to go unpunished. Throughout Germany, in all but a few places, they were burnt." Some Jews fled to the Kingdom of Poland, where King Casimir offered them protection and land, thus beginning the migration that was to make Eastern Europe the world center of Jewish population and culture by the end of the seventeenth century.

What was this disease? As the Church turned to the Bible to understand why it had come, medical scholars turned to the literature of antiquity to understand its nature. The medical inquiry was not an intellectual pursuit separate from Church doctrine. Medieval medical studies were a branch of theology, and the Church's understanding of the world was considered all-encompassing and infallible. God was believed to be the First Cause in nature and the universe, and medieval orthodoxy held that divine law and natural law were a unity, however imperfectly understood by human reason. Thus the laws of nature described in the writings of ancient Greeks and Persians were compatible with the authority of the Church and biblical revelation. The Church actively discouraged any form of experimentation or observation of the natural world.

Men who studied medicine in the fourteenth century had no understanding of disease biology. In October 1348 King Philip of France asked the medical faculty at the University of Paris, then the most prestigious in Europe, to explain the natural causes of the pestilence. After consulting authoritative ancient sources, the learned doctors of Paris reported that the Black Death arose because of a conjunction of the planets Saturn, Jupiter, and Mars in the sign of Aquarius. They stated the precise time of this evil conjunction to be 12 o'clock noon on the 20th of March 1345. At that moment there occurred a deadly corruption of the air, drawn from out of the earth by Jupiter and ignited by Mars. "We believe that the present epidemic…has arisen from air corrupt in its substance," they declared, "(which) can penetrate quickly to the heart and lungs to do its damage." Other contributing causes mentioned in their report were earthquakes, which also released corrupt air, and unseasonable weather bringing pestilential winds from the south. "Bad air," a "miasma" spreading disease from person to person, became the most widely accepted natural cause of the Black Death. The disease could also kill by sight according to a doctor at the University of Montpelier, "…as soon as the airy spirit leaving the eyes of the sick man has struck the eye of a healthy bystander looking at him, for then the poisonous nature passes from one eye to the other…."

At the end of the report to King Philip, divine will was mentioned as the ultimate cause of disease, but the good doctors of the University of Paris hastened to add that this did not mean forsaking doctors, because God cures the sick through the medicine He provides. Indeed, the medieval medical profession could claim some accomplishments. It could set broken bones and amputate limbs. It could close wounds and knew how to cauterize to stop bleeding. It possessed herbal remedies for minor aches and pains, menstrual cramps, and upset stomach. It even dabbled in brain surgery. But medieval doctors were limited in the scope of their medical understanding by a reliance on theory rather than practical experience.

Medicine had advanced little beyond the teachings of ancient Greeks, and the medieval doctor's principal textbook was written 1,000 years earlier by Galen, the second-century Greek physician. Galen was a strong advocate of the need to understand the workings of nature, but his writings had become a medical fossil stripped of any spirit of inquiry. He was read by medieval doctors as one who could provide unquestioned answers. According to Galen, all illness resulted from an imbalance of fluids in the body. Bodily fluids could be thrown out of balance by bad food or drink or poisonous air entering the body, and then one became sick. There was no theory of disease contagion. Galen's recommended treatments were consistent with the concept of bodily imbalance. The most common treatment was bleeding to reduce an excess of hot fluid and restore proper balance.

Doctors were scholar-priests trained at the universities under the supervision of the Church. The doctor's role was diagnosis, and he never touched his patient. Surgeons learned their skills as apprentices without university training, and they closed wounds, set broken bones, and bled patients. Professionally and socially surgeons were second-class citizens, and only the universities of Bologna and Padua accorded surgery enough respect as a medical discipline to include it in their curricula. Herbal medicines from cook-book recipes were important, and a medication called theriac, composed of herbs and roasted snake meat, was popular with doctors as both a preventive and a cure. An eminent doctor from Perugia, Gentile da Foligno, added gold to his formulation of theriac, and for the most discerning - and rich - patients, he also recommended powdered emerald, "a remedy so potent," he wrote, "that, if a toad looked at it, its eyes would crack." It should be noted that Gentile himself died of the pestilence in June 1348. Doctors cautioned patients not to sleep on their backs because foul air was more likely to enter their nostrils and flow into their lungs. To ward off bad air, doctors recommended holding bouquets of sweet-smelling herbs and flowers under the nose and burning aromatic wood in the fireplace. The learned doctors of Paris warned: "Bathing is injurious…Sleep in daytime is detrimental…Going out at night is dangerous…Fat people should not sit in the sun…Olive oil as an article of food is fatal…(In times of pestilence) men must preserve their chastity (if) they value their lives."

While many Europeans gave themselves up to despair or set about to enjoy their last days, the city-states in Italy took action in an attempt to cope with the disaster. What the practical men who governed could see before them led to an understanding that the Black Death was highly contagious. Boards of Health were set up with sweeping powers. Ships entering Italian ports were isolated for a biblically-derived period of forty days - quaranta giorni - from which comes the word "quarantine". Strangers and the sick were prohibited from entering cities on pain of summary execution, and diseased citizens were ordered to go into the fields beyond city walls to recover as best they could. Immediate burial of the dead was decreed, and mass burials were organized. The city of Milan, controlled by the ruthless Visconti family, ordered houses containing sick people walled up, entombing sick and healthy inhabitants together. The rich fled to their country homes, providing Boccaccio with a setting in which to place the ten young noblemen and women in his novella, The Decameron. However, no remedies in 1348, civic or personal, were successful in halting the progress of the pestilence or controlling its lethal effects.

After the Black Death it was obvious that neither the Church nor doctors had been able to offer protection. Boccaccio wrote that "the countless petitions humbly directed to God by the pious…(were) ineffectual, and all the advice of physicians and all the power of medicine…(was) unavailing…." A leading French physician wrote that the Black Death was "shameful for the doctors, … especially as (fearing) infection they hesitated to visit the sick." The Church, which subordinated the body to the soul, and doctors with their potpourri of false theories and quack treatments, were both revealed as incompetent in the realm of healing.

The most immediate effect of the Black Death was a psychological state of despair and pessimism. The medieval preoccupation with death became an obsession. Images of death in painting became more common, both as skeletal horse and rider and as witch figures with snakelike hair, bulging eyes, and clawed feet. Scenes entitled the Dance of Death, with the living and the dead gripping each other tightly, and the Triumph of Death, with the dead preying on the living, appeared in paintings across Europe. There was also a striking change in the depiction of Christ in painting. The Florentine painter Orcagni and his followers replaced Christ the gentle babe in the arms with a standing, staring Christ the King of Judgement.

Literature also reflected the turn toward pessimism. Boccaccio's witty Decameron, with its playful stories of love and folly, was followed by his sour satire, Il Corbaccio, The Crow, in which love is degraded and physically revolting, and women are greedy harpys concerned only with clothes and lovers. Shortly before he died in 1375, Boccaccio condemned his Decameron in a letter to a friend, begging his friend that women in the house not be allowed to read it because they would judge him "shameless, foul-mouthed and malignant, eager to spread tales of the dissoluteness of others…." In an anonymous English poem entitled "A disputation betwixt the body and worms", the corpse of a beautiful woman protests to the worms that are devouring her. In the poem's prologue she urges the reader to "think on death". A snarling poem by the Englishman John Gower, "The Voice Crying", attacks the sins of the time and reminds readers that they will end with "no more than a narrow wooden box…."

By the beginning of the fifteenth century, however, spirits had risen in the city-states of northern Italy, and this positive change in thinking can be traced in part to changes that occurred in medicine. With ancient theories discredited, the medical faculties at the universities of Bologna and Padua sought to establish a better understanding of medicine. Bologna had already departed from convention by including surgery and human anatomy in its medical curriculum. The first recorded human dissection for the purpose of instruction was performed at Bologna in 1315, despite a standing papal injunction against mutilating corpses. From Bologna dissection and the study of anatomy spread to the University of Padua. After the Black Death the teaching of surgery was intensified at these universities, a process made easier by the death of most of the old guard medical establishment during the epidemic. Dissections were done more slowly and in all seasons rather than in winter only. Padua also took a first step toward the scientific method by challenging medical theories with observable facts and proposing alternative theories based on analysis of natural phenomena. Medical instruction at the universities of Bologna and Padua was soon considered the best in Europe, and students came from other countries to learn the new ideas and procedures. The spread of new medical investigation was aided by the Pope's personal physician, who was trained as a surgeon and persuaded the Pope after the Black Death to permit the dissection of executed criminals for medical instruction.

The rise of surgery and the gradual transformation of medicine that began in Bologna and Padua after the Black Death was based on the belief that practical experience could lead to an understanding of the workings of nature. Having literally taken the study of medicine into its own hands, the medical profession in Italy acquired new confidence in its powers to heal. Medicine's increased understanding of human anatomy also gave Italian painters and sculptors a true image of human structure. Medicine became the first medieval field of endeavor to believe it had surpassed the knowledge of the ancients, and its optimism and spirit of inquiry at the end of the fourteenth century were among the forces pulling Italian society forward into the Renaissance.

How do we today answer the question, "What was the Black Death?" For most of the twentieth century there was a consensus that the Black Death was an epidemic of bubonic plague. British and French doctors in colonial service during the nineteenth century provided medically accurate descriptions of the disease in Asia, and in 1894 bubonic plague was scientifically identified by a Swiss microbiologist in China. The most prominent symptom of bubonic plague is the formation of a large, painful glandular swelling, or "buboe", most commonly in the groin. Reference to buboes is found in fourteenth-century chronicles, and this match of symptoms led Europeans to conclude that the Black Death was caused by the bubonic plague bacillus

Bubonic plague as the cause of the Black Death was universally accepted throughout much of the twentieth century. The first breach in this orthodoxy occurred in 1984 when British microbiologist Graham Twigg pointed out many inconsistencies between modern knowledge of bubonic plague and documentary evidence of the Black Death. He concluded that anthrax was a more likely candidate. Twigg's ideas were dismissed by most historians, but a small number of heretics with similar misgivings have mounted a growing challenge to the belief that bubonic plague caused the Black Death.

The most problematic aspect of bubonic plague as a cause is the great speed with which the Black Death traveled, covering a distance of 4,000 miles from the Crimean Peninsula in just four years. By contrast, bubonic plague took 40 years to travel a distance of less than 1,000 miles in China during the nineteenth century. Medieval commentators were astounded at the speed with which the Black Death appeared to pass from person to person, while British doctors in nineteenth-century India were struck by how infrequently bubonic plague was transmitted directly between people. "One (nineteenth-century) plague report after another concluded that the safest place to be in times of plague was the hospital plague ward."(

Bubonic plague is a bacterial disease of small mammals that can be transmitted to humans by infected fleas. The most common pathway for the disease to humans is the rat, but rat fleas do not seek out humans unless their rat hosts die. The rapid geographic spread of the Black Death by bubonic plague, as one skeptic noted, requires us to imagine an army of infected rats, creatures that rarely stray 200 yards from their nests, swarming long distances over the European countryside from town to town as they spread the epidemic. Other significant points of difference have been identified between modern bubonic plague and medieval records, most notably numbers killed, duration of disease, and seasonal patterns of infection. Absent from fourteenth-century chronicles is any mention of the large-scale rat mortality observed in the nineteenth century, a necessary precondition to human infection. Finally, as historian Samuel Cohn observes in his exhaustive study of the subject,( the famous "buboe", or glandular swelling, though almost always present in bubonic plague patients, is mentioned in only a small percentage of the many surviving Black Death chronicles. Spots or boils covering the body and other symptoms not typically associated with bubonic plague are much more frequently mentioned. Having reviewed all available evidence, some thousands of fourteenth-century documents, Professor Cohn concludes that bubonic plague could not have been the cause of the Black Death.

If the Black Death wasn't bubonic plague, what was it? The evidence strongly suggests a respiratory disease passing directly from person to person. A case has been made for some variant of anthrax, a respiratory disease endemic to cattle. Pneumonic plague, the respiratory form of bubonic plague, has also been put forward, although it is just a tiny fraction of modern plague cases and is almost 100% fatal. There are other bacterial and viral candidates among more than 100 diseases shared between humans and domestic animals. There is also, inevitably, the possibility of extra-terrestrial origin. Two scholars from Cambridge University, an astrophysicist and a mathematician, have proposed that the Black Death was "vertically transmitted" from outer space, falling from a passing comet. Closer to earth, there is the suggestion of a virus in the recent discovery that descendants of European Black Death survivors have a genetic mutation making them more resistant to the AIDS virus than other people. However, despite the possibilities, it is unlikely the Black Death will be conclusively attributed to a modern disease. It may have been a new disease that emerged, ran its course, and has since disappeared. The cause of the Black Death remains an unsolved mystery.

How will we in the twenty-first century respond to the emergence of a rapidly transmitted, deadly new disease? The Black Death is so far removed from us in time and modes of thought that it is easy to dismiss its chronicles as having little relevance to what we might experience. A more recent epidemic to consider is the great influenza of 1918. Early twentieth-century medicine had a good scientific understanding of infectious disease and many modern tools, including vaccination. Scientific research and clinical medicine were well developed in Europe and established in large cities in the United States. Public health, good nutrition, and pasteurization had dramatically reduced the death rates for tuberculosis, typhus, scarlet fever, polio, and other major diseases. Rudimentary antibacterial chemical treatments were available for syphilis and a few other infectious diseases. Medical specialization and antiseptic surgery were well developed. Broadly speaking, the medical elite in 1918 was thoroughly modern in its approach and had most modern tools and knowledge at its disposal, with the important exception of antibiotics.

Unlike the fourteenth century, the 1918 influenza was not preceded by rumors of far off disaster, although awful events were occurring in the trenches of World War I. But like the fourteenth century, established patterns of thought and behavior limited the effectiveness of society's response to epidemic disease. In 1918 governmental authorities were unprepared for the outbreak, and medicine was hampered by political agendas and firmly-held incorrect beliefs. In New York and Philadelphia, two of the cities hit hardest by influenza, public health departments were staffed by patronage appointees rather than those most qualified. In New York the commissioner of public health did not even have a medical degree. In most states there was no coordination between city, state, and federal health authorities, which often worked at cross purposes. The leading American microbiologist, Richard Pfeiffer, incorrectly identified bacteria as the cause of influenza, and his scientific stature and confidence in his discovery overcame all doubts and sent U.S. and European efforts to create a vaccine off in the wrong direction. In an attempt to maintain wartime morale, the true seriousness of the epidemic was kept from the public. For the same reason, effective quarantines were not imposed in some cities. Chicago health authorities rejected the advice of the Illinois superintendent of public health that places of business in the city be closed to save lives. Despite continuing mortality, Chicago's Public Health Commissioner later bragged, "nothing was done to interfere with the morale of the community."(

With governmental incompetence, lack of an effective medical response, and fear, many scenes described in the chronicles of the Black Death unfolded. As influenza mortality was at its peak in October 1918, the morgues in Philadelphia were overwhelmed. A city official reported that "it was impossible to hire persons willing to handle the bodies." Families dug graves themselves for their dead or placed wrapped bodies on the porch, where they were picked up by open trucks or horse-drawn wagons and taken without ceremony to mass graves. The U.S. Surgeon General's advice to avoid influenza mixed sound personal hygiene with preventive irrelevancies such as avoiding constipation and tight clothes and chewing one's food well. Without an effective medical treatment, doctors tried anything: heroin, strychnine, quinine, injected hydrogen peroxide, and bleeding. Nothing worked. In an atmosphere of growing public terror, where government and the press obscured the truth but repeatedly issued warnings not to be scared, quack notroms filled the void. Advertisements in local papers offered such influenza preventives as an herbal mix called gelsemium, camphor balls, garlic, Influ-BALM, and Father John's Medicine. After the disease had crested a medical response finally materialized with the development of a vaccine for pneumonia that reduced mortality caused by secondary bacterial infection. It was, however, only available to the Army.

During 1918 and 1919 influenza caused 50 million deaths worldwide, possibly as many as 100 million, and based on the experience of the United States and other countries with good medical records the mortality rate of those infected was around 10%. We still do not know why this influenza was so deadly, although the answer may be discovered in genetic research underway on virus samples recovered from the bodies of American World War I soldiers buried in Alaska. It is humbling to conclude that despite all its knowledge, early twentieth-century medicine was little more effective in controlling the 1918 influenza than medieval medicine was dealing with the Black Death. In both epidemics, quarantine was the only effective means employed.

How will human society cope with a future epidemic of super-contagious microbes? The outlook is unclear. Medicine has made tremendous advances since 1918, and there is a much higher level of global awareness and cooperation. But the parallels between 1918 and the Black Death suggest that some aspects of human behavior are more resistant to change. The interests of science are not always supreme in the realm of politics. In 2003, the world came close to an epidemic outbreak of the new SARS virus because the government of China kept it secret for months until it spread abroad. Earlier this year the governments of Thailand and Indonesia delayed announcement of large-scale avian flu outbreaks. In the United States, political agendas have harmed some areas of laboratory research, and the combination of litigation and price controls has reduced the number of vaccine manufacturers. Dark conspiracy theories about the harmful effects of polio vaccine and other immunizations flourish on the internet and in some African countries.

Beyond the blunt instrument of quarantine, vaccination is the best method of stopping an epidemic, but the manufacture of vaccine is confronted with practical problems. Laboratory formulation of vaccine takes months, even before considering the additional time-consuming requirements of regulation and clinical trial. Global vaccine manufacturing capacity is currently measured in hundreds of millions of doses per year against an estimated worldwide requirement of billions of doses necessary to stop a global pandemic. To protect the U.S. population alone against a 1918-level epidemic would require developing, producing, and administering 150 million vaccine doses in a 3-month period. This is twice the current U.S. annual capacity and has never been accomplished.( It is entirely possible that quarantine, the biblical 40 days confinement of the medieval Italy, will be human society's principle line of defense against the outbreak of highly contagious epidemic disease, as it was in 1348 and 1918.

In conclusion, I return again to Giovanni Villani in Florence of 1348 and the choice he posed between blind chance or divine retribution. Around the time he wrote his question Villani also made a closing entry in his chronicle of Florence: "And the pestilence ended in the year _________." Here he left the date blank, to be filled in by a survivor. Perhaps he was not feeling well. Shortly after this last entry the Black Death caught him and he died. His brother, Matteo, survived the epidemic and continued the chronicle.

Today few of us would choose either of Villani's proposed causes of epidemic disease. Instead we would seek natural causes and remedy in the tools of laboratory science. But it would be unwise to exclude the role blind chance may play should another epidemic disease emerge. Recent history suggests there are many opportunities for unscientific decisions in the realm of politics. Microbes have enough advantages without placing blind chance on their side as well. Human society must have the wisdom to use its medical knowledge effectively. If not, the outcome may be determined by blind chance, which could be considered a modern form of divine retribution.

( Horrox, ed., The Black Death, p. 82

( Cohn, The Black Death Transformed, pp. 2-3

( Cohn, ibid.

( Barry, The Great Influenza, p.337

( Meltzer, Martin I., et al, "The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention"

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