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  For Mom and Dad.

  Would it kill you to go to the doctor now and then?

  What’s natural is the microbe. All the rest—health, integrity, purity (if you like)—is a product of the human will, of a vigilance that must never falter.

  —ALBERT CAMUS, The Plague

  I’ve got chills.

  They’re multiplying.

  And I’m losing control.

  —JOHN FARRAR, “You’re the One That I Want,” Grease

  Introduction

  When I tell people that I am writing a book on plagues, well-meaning acquaintances suggest I add a modern twist. Specifically: “You know, like how we’re all on our cell phones all the time.” Or selfies. A chapter on selfies.

  Then I reply, “No, my interest lies more with the kind of plague where you break out in sores all over your body and countless people you know and love die, rapidly, within a few months of each other, in the prime of their lives. And there is nothing you can do, and everyone is dead, and everything is death, and all of earth seems to be a vast wasteland of corpses, and, wait, here, allow me to show you some absolutely horrific pictures.”

  And then they say, “Excuse me, I’m just going to get another drink.”

  I am so happy you picked up this book because often, when I’m out chatting with people, no one really likes to hear about diseases of the past. I suspect that disinclination is largely due to plagues seeming both very grim and very remote. It’s generally better just to say that I like selfies. I think they’re fun. I like seeing pictures of my friends’ smiling faces. I like how alive they all are.

  It does appear that we are living in a world where the word plague has shockingly little meaning for many. To the extent that they think about plagues at all, many associate them with muddy huts, textbooks they had to read in sixth grade, and, if they are film buffs, a death figure who has a truly bewildering interest in chess. People in core countries seem to expect to die at age ninety in a nursing home. They do so with good reason: if conditions continue uninterrupted, 50 percent of the children born in the year 2000 will live to be a hundred years old.

  If conditions continue uninterrupted.

  We have been living in an age of improbable luck. We have experienced nearly thirty years without a disease—that we do not know how to combat—killing upward of thousands of otherwise healthy young people in those core countries. I can’t say whether this good fortune will run out—I hope it won’t—but it always has in the past. We just like to forget this disagreeable fact. Forgetting is soothing and probably in our nature. But disregarding, and being ignorant of, plagues of the past makes us more, rather than less, vulnerable to inevitable ones in the future.

  Because when plagues erupt, some people behave amazingly well. They minimize the level of death and destruction around them. They are kind. They are courageous. They showcase the best of our nature.

  Other people behave like superstitious lunatics and add to the death toll.

  I wish I had the scientific knowledge to talk about how to make vaccines or cures that might eradicate illness, but I don’t. This book isn’t just for future Nobel Prize winners, as much as I am impressed by and rooting for them. Because whether plagues are managed quickly doesn’t just depend on hardworking doctors and scientists. It depends on people who like to sleep in on weekends and watch movies and eat French fries and do the fantastic common things in life, which is to say, it depends on all of us. Whether a civilization fares well during a crisis has a great deal to do with how the ordinary, nonscientist citizen responds. A lot of the measures taken against the plagues discussed in this book will seem stunningly obvious. You should not, for instance, decide diseased people are sinners and burn them at a literal or metaphorical stake, because it is both morally monstrous and entirely ineffective. Everyone would probably theoretically agree with this statement. But then a new plague crops up, and we make precisely the same mistakes we should have learned from three hundred years ago.

  I recently read in a history book that you ought not view the past through a modern-day lens. It supposed that instead you should consider different eras as entirely separate, like, I imagine, sausage links. I thought the writer seemed to show a fundamental lack of understanding of how time works. The past does not exist under a bell jar. Moments, ideas, and tragedies of the past bleed into the present. Alas, some of the ideas that make it into the present consciousness are not the best. I found, for instance, that some people still feel justified hating Jews because they think they started the bubonic plague by dumping diseased material into wells. (This is, as we’ll examine, impossible.) Worrying whether people preparing your food are washing their hands thoroughly has a lot to do with the contagious disease-carrying cook Mary Mallon, aka Typhoid Mary. If moments from the past seep so seamlessly into the present, maybe moments from the present can help us relate to the past. After all, the past was no less ridiculous than the present. Both eras were made up of humans.

  One of my great wishes is that people of the present will see those of the past as friendly (or irritating) acquaintances they can look to for advice. It’s easy to forget that people from the past weren’t the two-dimensional black-and-white photos or line drawings you might encounter in some dry textbooks. They weren’t just gray-faced guys in top hats. They were living, breathing, joking, burping people, who could be happy or sad, funny or boring, cool or the lamest people you ever met in your life. They had no idea they were living in the past. They all thought they were living in the present. Accordingly, like any person, past or present, could be, some of them were smart and kind and geniuses about medicine and also completely dull on a personal level. (I’m trying to come to terms with loving John Snow’s deductive brilliance and being absolutely certain I would never want to spend more than ten minutes talking to him.) Others were charismatic and charming and total sociopathic maniacs. (That description gives Walter Jackson Freeman II too much credit for charm, but people liked him. He was gross, and he wore a weird penis ring on his neck. People should not have liked him for numerous reasons.)

  You should regard everyone in this book as human, not inanimate historical figures. We can have personal opinions about them; we’re not all that different from them. And despite what some breathtakingly stupid intellectuals would have you believe, the people and interests of the past weren’t necessarily smart and serious any more than the people and interests of the present are dumb and frivolous. Knowing about pop culture doesn’t make you dumb; it makes you a person who is interested in the world you live in. Besides, it is impossible to believe that everyone in the past was a serious figure meriting great respect once you learn that one guy thought tubercular patients should take up new careers as alligator hunters.

  I am always hopeful that the more we demystify the past—and the more we laugh about it and toss around information about it with the same enthusiasm we have for discussing our favorite TV shows—the
better off we will be. Because if or when the next plague comes, I hate the idea that the only people who are familiar with Paracelsus (loved mercury, hated women) are going to be elderly academics in tweed coats who discuss him with pseudo-British accents. When the next outbreak comes—and I lack the optimism to believe it won’t—so many of our challenges will remain the same. We will be so much better off if the absolute maximum number of present-day and future people handle the disease with the aplomb of some of the best figures in this book. And let’s be honest, that guy in the tweed coat with the on-again-off-again accent is going to die first.

  I’m invested in this study of diseases because I think knowing how diseases have been combatted in the past will be helpful in the future. If you’re someone who intends on living into the future, I hope you will be, too.

  And don’t worry. You don’t need to flee for another drink. I’ll keep the horrific pictures to a minimum. Despite the considerable odds against it, I’ll try to make reading and learning about these dark times in human history a lot of fun.

  Antonine Plague

  When you arise in the morning,

  think of what a precious privilege it

  is to be alive—to breathe, to think, to

  enjoy, to love.

  —MARCUS AURELIUS

  Every so often—frequently when consenting adults are reported to be having sex in some manner that would have been banned in the Victorian age—a TV commentator will shake his head and discuss how this behavior led to Rome’s final days. Often it seems those pundits have a poor understanding of kindness, compassion for one’s fellow man, and the progressive flow of social mores. And we can absolutely say they always have a poor grasp of “Rome’s final days.”

  To be clear, the Roman Empire didn’t end because everybody was having sex. No civilization was ever toppled by “too much sexy time”—except for Bavaria in 1848, but that is an unrelated (if delightful) story.

  The beginning of the final days of Rome wasn’t caused by heartwarming weddings between gay people. It began with a plague that erupted in the 160s. At that very time Romans were at the height of their power and their massive empire stretched from Scotland to Syria.

  They were able to conquer and defend such a huge empire because the Roman army was a massive force. During the period around 160, the army consisted of twenty-eight legions composed of 5,120 men each. The legionnaires volunteered to serve for twenty-five years, after which time they could retire with a generous pension of about fourteen years’ pay. And in case 143,360 men in the army seems a little light—for comparison there are currently approximately 520,000 active duty soldiers in the United States—there were additional auxiliary armies that made up about another 60 percent of the force. Those were often composed of noncitizens who, if they survived their years of service, were granted Roman citizenship.

  Now, you may wonder, Yes, but who would survive twenty-five years in the military? If you were a Roman soldier, your chances of staying alive during the period 135 to 160 were actually comparatively reasonable. While the exact statistics are unknown, it was a time of relatively few battles. You might not even have to fight. Walter Scheidel, a professor at Stanford University, writes: “For all we can tell, the 239 veterans (representing two years’ worth of releases) who were discharged from legio[n] VII Claudia around AD 160 had not experienced substantial combat operations during their twenty-five or twenty-six years of service.”1

  Those troops didn’t see action in twenty-five years. I bet they were laughingstocks. But that’s a good thing! They did not have to fight, ever!

  If they did see battle, the Roman troops were stunningly, perhaps even unnecessarily, well equipped. The legionnaires were outfitted with lorica segmentata, an extremely flexible armor made of metal strips. The first-century historian Josephus described the impressively arrayed Roman army: “They march forward, everyone silent and in correct order, each man maintaining his particular position in the ranks, just as he would in battle. The infantry are equipped with breastplates and helmets and carry a sword on both sides. The infantry chosen to guard the general carry a javelin and an oblong sword. However, they also carry a saw, a basket, a shovel, and an ax, as well as a leather strap, a scythe, a chain, and three days’ food rations.”2 They were like the Swiss army knives of soldiers.

  So the Roman army had great armor, great numbers, great training, and in some cases at least three days of food on them at all times. Shortly after this, they’d begin losing battles and cities to the Germanic tribes.

  I initially thought that the Germanic tribes must have had some fairly cool equipment to successfully combat the Imperial Roman army. Fortunately, Tacitus was there to set me straight. The Germanic tribes fighting them were pretty much naked. The historian wrote of at least one Germanic tribe: “They are either naked, or lightly covered with a small mantle; and have no pride in equipage: their shields only are ornamented with the choicest colors. Few are provided with a coat of mail and scarcely here and there one with a casque or helmet.”3 I especially like that Tacitus took time to scoff that the German shields were artistically weak. The Encyclopedia Britannica, in an instance of unusually helpful specificity, backs up Tacitus, explaining that the Germanic tribes would all be horribly ill equipped until the sixth century:

  Their chief weapon was a long lance, and few carried swords. Helmets and breastplates were almost unknown. A light wooden or wicker shield, sometimes fitted with an iron rim and sometimes strengthened with leather, was the only defensive weapon. This lack of adequate equipment explains the swift, fierce rush with which the Germans would charge the ranks of the heavily armed Romans. If they became entangled in a prolonged, hand-to-hand grapple, where their light shields and thrusting spears were confronted with Roman swords and armour, they had little hope of success.4

  In spite of their inferior equipment the tribes were incredibly courageous. Women fought alongside men, sometimes with their children. For many, their greatest wish was to die a glorious death in battle. The nineteenth-century historian John George Sheppard describes the German tribes: “Though often defeated, they were never conquered; a wave might roll back, but the tide advanced; they held firmly to their purpose till it was attained; they wrested the ball and sceptre from Roman hands, and have kept them until now.”5 The Germanic tribes were willing to continually attack the Roman Empire despite being outnumbered and possessing inferior armor and weaponry. They were ready. They lived for battle. They had been threatening, though failing to penetrate, the empire’s borders since being defeated by the Roman general Gaius Marius in 101 BC. I’m not saying that it was surprising that they attacked. I am saying they never should have won. The best army in the world still, logically, shouldn’t have been defeated by a bunch of nearly naked people with presumably taupe-colored shields.

  But the tribes had the strongest ally in the world on their side. It wasn’t human. It was the Antonine plague.

  The expanse of territory the Roman troops covered would prove to be their undoing This plague came to Rome from Mesopotamia around AD 165–66. It was carried home by Roman troops who had been fighting in that region. And when it arrived in Rome it was a nightmare. A nightmare even by the standards of people who were used to disease.

  Although we may rave about how technologically advanced Rome seemed compared to the Dark Ages following Roman civilization’s collapse, it was imperfect. There were public latrines, but few private houses were connected to public sewers; many people dumped their waste directly onto the streets. The Tiber River was also prone to flooding, which meant (forgive this description but there’s no other clear way to say it) that a river of shit would occasionally flow through the streets. And though people used bathhouses, the water they bathed in wasn’t disinfected and frequently contained bacteria. As you might expect, malaria, typhoid, dysentery, hepatitis, and cholera all thrived during the period, yet the historian Edward Gibbon claimed this was the age during which, “the human race was most happy and pro
sperous.” I should cut Gibbon a little slack here—he published his Decline and Fall of the Roman Empire beginning in 1776—but pretending any historical age before proper indoor plumbing was a glorious epoch is a ludicrous delusion. Frank McLynn, a modern-day historian, writes in Marcus Aurelius, A Life: “Horrific as malaria and all the other deadly diseases were, Romans absorbed them as part of daily existence; slaves and other wretched of the Earth were already living a death-in-life, so they may not have been unduly perturbed by the approach of the Reaper. But the ‘plague’ that hit Rome under Marcus Aurelius was entirely different, both in degree and kind, from anything Romans had experienced before.”6

  Much of what we know about the nature of this plague is taken from the writings of Marcus Aurelius’s physician, Galen. In fact, the Antonine plague is even sometimes called the Plague of Galen.

  Although Galen was a great physician, he was not a terribly courageous man. Galen was a self-promoter above anything else. According to McLynn, he consistently claimed to be a self-made man, casually downplaying the fact that he came from an extremely wealthy family and had inherited numerous estates as well as a stellar list of contacts. He employed underhanded tactics to win debates, and he constantly aggrandized his own achievements. Personality-wise, you could think of him as the Donald Trump of ancient Rome. He was also something of a coward when it came to disease. Now, I don’t think cowardice is an abnormal reaction in life-or-death situations; it can be very similar to intelligent self-preservation. I fully expect that I would be weak and spineless in a plague. However, it’s not a great trait in a physician.

  Tiny little hands not pictured.

  Galen came very close to not recording this plague at all. When the disease began breaking out in 166, he fled Rome for the less disease-ridden countryside. He claimed he was leaving Rome not because he was understandably scared, but because all the other physicians were so jealous of him and his awesome skills that Rome just wasn’t a cool place to be anymore. We don’t know exactly where he was from 166 to 168, only that he was summoned back to join Marcus Aurelius in Aquileia (today northern Adriatic Italy) in 168. One year later, when the outbreak worsened in that region, Galen told Marcus Aurelius that the Greco-Roman god of medicine Asclepius had come to him in a dream and said that Galen should go home to Rome for sure. Galen claimed the god regularly chatted with him in his dreams and gave him advice on a number of medical matters. I don’t put it past Galen to use an “a god told me to do it” excuse to remove himself from danger, but it’s also possible that he did believe these messages. Marcus Aurelius mercifully allowed Galen to return to Rome, where he spent the rest of his life as the private physician to the future emperor Commodus. He lived, seemingly very happily, into his eighties—a major accomplishment considering the generally shortened life spans of his era.