Part 1: Sacred Diseases

As the Covid infections have ticked upwards and lockdowns have dragged on there’s been plenty of time to dwell on our current situation.
The artist Leo von Klenze was an architect for the Court of the Bavarian King, Ludwig I during the early 18th century. Klenze studied ancient architecture during his travels to Italy and Greece. He also participated in excavations of ancient buildings in Athens and submitted proposals for the restoration of the Acropolis. Leo von Klenze /

If we’re lucky we’ve been confined to a narrow corridor between home, the supermarket and the local dog park. If we’re unlucky we’ve had to return to work despite the risk of sickness and death.

It’s easy to feel like this crises is unique and that society has been totally blindsided by the virus. That’s certainly the impression you’d get from the media coverage. So far 2020 has generated two graphs with vertiginous growth – one representing the infection rate and the other representing journalists’ use of the term ‘unprecedented’.

But the historical record reveals plenty of precedent for our current situation. Sharing space with animals and the diseases they carry appears to be one of the essential trade-offs of living in settled societies. In the archeological record we can find evidence of contagious diseases going back to the Bronze Age with traces of the plague bacterium Yersinia pestis recently discovered in the remains of a woman buried in Scandinavia more than 5000 years ago.

What’s unprecedented about the current epidemic is that, for the first time in history, humanity as a whole actually shares an understanding of how diseases spread and how they can be contained. While a small minority seem to be dithering when it comes to specific preventative measures, by and large, we’re all reading from the same playbook. The public health advice to residents of Timbuktu in Mali is the same as that provided to residents of Suva in Fiji and everywhere in between – avoid gatherings, wash hands and wear a mask.

The measures themselves may be simple but reaching the current consensus has taken thousands of years and millions of lives. For most of recorded history the basic mechanisms of contagion were a mystery. Most communities endured outbreaks of communicable disease using some combination of prayer, astrology, folk remedies and pseudoscience.

To appreciate how far we’ve come we need to examine not only the origins of medical science but also the first attempts to set up an organised public health system. Greek and Roman philosophy offers an insight into the former but to find a prototype for the modern public health system we need to look at the early Byzantine Empire and its rival – the Rashidun Caliphate. Their novel approaches to welfare and public health formed the template for the hospitals and clinics we now take for granted.

Reading about the history of ancient pandemics can be incredibly dispiriting. At times it feels like nothing more than a long list of death tolls and mass graves but beneath the statistics you can find valiant attempts by individuals and communities to make sense of something that must have seemed utterly senseless. We should probably be more understanding toward the witch doctors and the astrologers of history. Until Leeuwenhoek began producing his crude microscopes in the late 17th century the microbial forces that shaped our world were literally invisible to us.

The challenge for physicians and philosophers of the ancient world wasn’t just one of imagination. They also had to reconcile their theories with the religious beliefs that governed their societies. It’s easy to assume some longstanding conflict between religious and natural explanations for the world around us but, for most of our history, these two concepts were tightly woven together. Gould’s notion of ‘non-overlapping magisteria’ may be diplomatic but it would have been a very foreign concept to most of our ancestors.

For philosophers and physicians there were also fundamental constraints when it came to storing and transferring knowledge through the generations. Every insight and discovery that was made in antiquity represented a tenuous step forward that could easily be erased by some political or natural disaster. Throughout most of history written records were only available to the tiny fraction of the population that were literate who happened to live near one of the few centres of knowledge and scholarship. Even then, one unsupervised candle could undo centuries of careful observation and inference.

Despite the vulnerability of early scholarship there were documents that stood the test of time and, in that early cannon, two figures loom larger than any others – Hippocrates of Kos and Galen of Pergamon. These two philosophers lived in two different Empires several centuries apart but, together, they established theories of illness and health that stood virtually uncontested for hundreds of years. Their understandings and misunderstandings of biology cast a long shadow over our collective effort to deal with contagious disease.


Hippocrates of Kos

Hippocrates was born on the island of Kos in the 5th century BC. He trained as a physician during the Age of Pericles – a brief period of prosperity during which most of the Greek city-states were at peace with one another. It’s during this period that Plato and Socrates established their schools of philosophy and when some of Athens’ most famous monuments – including the Parthenon – were erected. Hippocrates is believed to have traveled widely during his life – practising and teaching medicine in a number of cities across Greece and its colonies. Together with his followers Hippocrates consolidated a wealth of medical knowledge and set down best practices for physicians in what became known as the Hippocratic Corpus.

Ancient Greek society was very familiar with contagious disease and plagues feature prominently in the popular culture of the time. In the tragedy Oedepis Rex Sophocles describes a plague in the city of Thebes that afflicts not only humans but plants and animals too. In the very first lines of Homer’s Iliad the god Apollo punishes Agamemnon’s army for kidnapping the daughter of one of his priests. According to the poem Apollo the ‘God of Plague’

“came down like night and let fly his pestilence-laden arrows from his silver bow. He cut them down in droves and the corpse fires burned on, night and day, no end in sight. Nine days the arrows of the god swept through the army.”

According to Greek mythology Apollo’s arrows could also cure disease and his son Asclepius was venerated by the Greeks as the god of healing. During Hippocrates’ era the cult of Asclepius was widespread in the Greek world and its symbol – a snake wrapped around a staff – is still used occasionally to represent medicine in the modern world.

While superstation dominated the popular understanding of illness Hippocrates contested many of the prejudices of his time. In his treatise The Sacred Disease he rejected the idea that conditions like epilepsy were a curse from the gods that could be lifted by rituals and magic spells.

“I do not think that the body of man can be stained by a god, the most perishable thing there is by the most holy; for even if it happened that the human body, under the effect of some other thing, acquired a stain or were damaged, I think that it would be purified and sanctified rather than stained by a god”

When it came to contagious disease Hippocrates helped establish the theory that bad air or ‘miasmas’ were to blame for illnesses that effected large number of people. Swamps, marshland, corpses, manure and other things that decomposed were all thought to pollute the air. This miasmatic theory of disease would persist well beyond the ancient world and stemmed from a sort of deductive reasoning. In one of the texts attributed to Hipporates he explained that:

“when a single disease affects a great number of individuals at the same time, we must attribute this to the most common cause, to that which we all use the most; and this is what we breathe. Indeed, it is clear that individual regimen cannot be the cause of the disease, since it attacks everyone, young and old, women and men and, without distinction, those who drink wine and those who drink water, those who eat barley bread and those who eat wheat bread, those who do a lot of exercise and those who do little”

Thucydides and the Plague of Athens

During the lifetime of Hippocrates we get one of the earliest first-hand accounts of an epidemic from Thucydides’ description of the Plague of Athens. Thucydides was an Athenian statesman and historian who witnessed the outbreak during the first Peloponnesian War when thousands of Athenians took shelter inside the city walls to escape the Spartan army. The sudden influx of refugees and the lack of sanitation triggered an epidemic that devastated the population.

In his History of the Peloponnesian War Thucydides described a truly unprecedented crisis.

“Though no pestilence of such extent nor any scourge so destructive of human lives is on record anywhere. For neither were physicians able to cope with the disease, since they at first had to treat it without knowing its nature, the mortality among them being greatest because they were most exposed to it, nor did any other human art prevail. And the supplicants made at sanctuaries, or appeals to oracles and the like were futile, and at last men desisted from them, overcome by the calamity”

Despite Thucydides’ detailed description of its symptoms the exact pathogen responsible for the Plague of Athens is still unknown. Recent research suggests it may have been some form of viral hemorrhagic fever (of which ebola is an extant example) but it’s unlikely we’ll ever know for sure. Thucydides was one of the lucky few who contracted the disease and recovered. Most died. The plague claimed the life of Athen’s great general Pericles and wiped out over 30,000 citizens – somewhere between one-third and two-thirds of the Athenian population. The Peloponnesian War continued for another 26 years until Athens and its allies were finally defeated.

Cassius Dio and the Antonine Plague

Five hundred years later another epidemic was unleashed on the Roman Empire by soldiers returning from the siege of Seleucia in present-day Iraq. While there’s never a good time to have a plague our current crisis shows that political leadership can make a huge difference. The plague that spread across Rome’s Empire in 165 AD started during the reign of Emperor Marcus Aurelius Antoninus and became known as the Antonine plague but, while Marcus was regarded as an outstanding statesman and leader, he handed the reigns of his Empire to his son Commodus who was, by all accounts, a complete psychopath.

The historian Cassius Dio witnessed the Antonine plague and recorded that, at its height, the plague claimed two thousand people a day in the capital. The new Emperor, however, largely ignored the unfolding disaster. Instead he spent most of his time and vast sums of the Roman treasury on gladiatorial and chariot events to aggrandise himself.

However bad the epidemic may have been Dio insists that Commodus’ reign itself was more harmful to Rome than any disease. Drunk on power the Emperor (memorably played by Joaquin Phoenix in the film Gladiator) commissioned hundreds of statues of himself in the style of Hercules and replaced the head of Rome’s famous ‘Colossus’ statue* with his own likeness. He renamed city, the senate and the months of the year after himself and declared the start of his new era Dies Commodianus.

Anyone who tried to reign in Commodus’ excesses ran the risk of being murdered or exiled. In his 80-book opus Roman History Cassius Dio assures his readers that;

“I should render my narrative very tedious were I to give a detailed report of all the persons put to death by Commodus, of all those whom he made away with as the result of false accusations or unjustified suspicions or because of their conspicuous wealth, distinguished family, unusual learning, or some other point of excellence”

Amid the political upheaval the Antonine plague is thought to have killed somewhere between 3.5 and 5 million people. As with the Plague of Athens a retrospective diagnosis for the Antonine Plague is difficult but it’s thought to have been some form of measles or smallpox.

Many historians consider the reign of Commodus’ and the outbreak of the Antonine plague to be the beginning of the end of the Roman Empire. Historian Edward Watts wrote that;

“The plague so ravaged the empire’s professional armies that offensives were called off. It decimated the aristocracy to such a degree that town councils struggled to meet, local magistracies went unfilled and community organizations failed for lack of members. It cut such deep swaths through the peasantry that abandoned farms and depopulated towns dotted the countryside from Egypt to Germany.”

Commodus’ assassination in 192 AD kicked off the infamous Year of the Five Emperors which was followed by a period of civil war and political strife that lasted well into the 3rd century.

French artist Jules Elie Delaunay depicts an angel commanding death to strike another Roman household with the plague.

Galen of Pergamon

While the political leadership of the era left a lot to be desired the Antonine Plague coincided with the career of one of the most exceptional physicians of the ancient world – Galen of Pergamon. The son of a wealthy Greek architect Galen began studying medicine at 16 at a prestigious Asclepieum (healing temples dedicated to Asclepius, god of medicine) in Pergamon near present-day Bergama on the Turkish coast. During his life Galen travelled all over the Empire, learning and teaching a wide range of medical theories before settling in Rome, where he served as an adviser and personal physician to several emperors.

While most of what went on at the Asclepieums would now be considered faith-healing Galen was a strong advocate for the scientific method when it came to physiology and anatomy. Roman law at the time prohibited human autopsies so Galen dissected barbary macaques and other primates to better understand the workings of the body. He also gained practical experience in trauma surgery and wound treatment as the chief physician at the gladiatorial school in Pergamon.

At the time Pergamon’s gladiatorial academy, the ludus, was run by the regional head of Rome’s imperial cult – the high priest of Asia. In his memoirs Galen described how he secured his position by disembowelling a monkey and challenging the high priest’s physicians to suture the wound. When none of them took him up on the offer he did it himself and went on to demonstrate the proper procedure for closing severed arteries to prevent blood loss. The high priest was apparently delighted by the gory demonstration and Galen proved his value over the following years. Reflecting on his track record at the ludus Galen wrote that.

“With the exception of two, none of the wounded in my charge died, whereas sixteen individuals had died under my predecessors. Later, another high priest put me in charge of the wounded, and in doing so he was even more fortunate. None of the patients under my care died, even though each suffered grave and multiple wounds”

Galen is most famous for his contribution to human anatomy and neurology but his writings had a longstanding influence on the entire field of medicine. When it came to the fundamental causes of disease Galen subscribed to the two basic premises established in the Hippocratic Corpus. The first was the theory of miasma that attributed collective sickness to ‘corrupted air’ and the second was the theory of humorism that attributed individual sickness to imbalances between four essential bodily fluids: blood, yellow bile, black bile, and phlegm.

Galen combined and expanded upon these two theories. He proposed that imbalances in a person’s bodily humors could make them them more susceptible to miasmas. Galen’s conclusion was that diet and lifestyle were crucial to avoiding illnesses of all sorts and escaping contagions took more than just avoiding ‘unwholesome’ and ‘corrupted’ air.

For the next thousand years Galen’s synthesis of humorism and miasma theory provided the basis for understanding contagious disease. We can still see traces of these theories in our names for highly infectious diseases like cholera (from the Greek ‘kholera’ meaning yellow bile) and malaria (medieval Italian for ‘bad air’).


The Cyprian Plague

Two generations later (between AD 249 and 262) another plague swept across the Roman Empire. While most historical plagues end up being named after the place where they started or the unfortunate person in charge at the time the Cyprian Plague appears to take its name from its biggest fan – the bishop of Carthage St Cyprian. In his treatise De Mortalitate Cyprian seems positively enthusiastic about death by plague.

“This trial, that now the bowels, relaxed into a constant flux, discharge the bodily strength; that a fire originated in the marrow ferments into wounds of the fauces; that the intestines are shaken with a continual vomiting; that the eyes are on fire with the injected blood; that in some cases the feet or some parts of the limbs are taken off by the contagion of diseased putrefaction; that from the weakness arising by the maiming and loss of the body, either the gait is enfeebled, or the hearing is obstructed, or the sight darkened;–is profitable as a proof of faith. What a grandeur of spirit it is to struggle with all the powers of an unshaken mind against so many onsets of devastation and death! what sublimity, to stand erect amid the desolation of the human race, and not to lie prostrate with those who have no hope in God; but rather to rejoice, and to embrace the benefit of the occasion; that in thus bravely showing forth our faith, and by suffering endured, going forward to Christ by the narrow way that Christ trod, we may receive the reward of His life and faith according to His own judgment!”

Cyprian’s belief that the ordeal of infection brought the sufferer closer to god became a template for the Church’s response to pandemics but, at the time, it was a fairly novel idea. By embracing sickness and death Cyprian gave Christianity a theological edge over the pagan cults that it was competing with at the time. Temples dedicated to gods like Apollo and Athena were predicated on immediate and somewhat practical outcomes – for improved harvests, for victory in war or relief from droughts and plagues. Christian dogma, on the other hand, was more concerned with salvation and was bound up in prophecies of judgement and tribulation.

Counterintuitively Christian fatalism might have ended up improving survival rate of its followers. In the first modern analysis of how diseases and pandemics shaped history historian William H. McNeill suggested that by continuing to minister to the sick early Christians might have increased their chances of survival despite the corresponding risk of infection.

“When all normal services break down, quite elementary nursing will greatly reduce mortality. Simple provision of food and water, for instance, will allow persons who are temporarily too weak to cope for themselves to recover instead of perishing miserably”

Although Christian and Roman sources from the era are heavily biased against one another, some evidence suggests that social mores broke down among the pagan population as Roman priests pinned their hopes on vast public sacrifices. At the same time many Christian communities appear to have continued to minister to one another and to perform the funeral rites that their pagan neighbours had largely abandoned.

Following the Cyprian plague the two halves of the Roman Empire were briefly reunited under Emperor Constantine who adopted Christianity as the official religion of the state and moved the capital from Rome to a city on the Bosporus called Byzantium. The city was renamed in his honour and Constantine’s armies reclaimed some of the territory that had been lost during the preceding turmoil. From his new capital Constantine could control the flow of goods arriving via the Silk Road and push the borders of the Empire outwards into Persia. As political power shifted east the centres for science and scholarship followed and, over time, many of the Greek theories fell out of use in Western Europe.

Constantine’s successors struggled to maintain control of the vast territory they inherited. In 337 AD the Empire encompassed the entire Italian peninsula, North Africa, Egypt, Spain, and most of what is now France and the Balkans but, by the end of the 4th century, the empire had split once agin into eastern and western territories. In 391 the great library in Alexandria, where Galen had studied, was destroyed by Christian fanatics. A few years later Rome was sacked by the Germanic army of the Visigoths but the Western Empire staggered on for a few more decades until another Germanic tribe – the Vandals – finally put it out of its misery.


Justinian’s Reforms

A brief revival of the old empire occurred in the mid 6th Century under the Byzantine Emperor Justinian. Justinian – the emperor who never slept – proved to be an incredibly ambitious ruler and he surrounded himself with a number of equally dedicated military and government officials. In a few short years his generals, Belisarius and Narses, re-conquered the Vandal Kingdom in North Africa as well as the Ostrogothic kingdom that ruled Dalmatia, Sicily and the Italian peninsula – temporarily ending ‘barbarian’ rule.

At the same time Justinian’s adviser Tribonian carried out a complete overhaul of the Roman legal system. Legal protections for women were expanded and patriarchal rights were reduced. New prohibitions were also put in place to combat heresy and paganism. Christianity at the time was riven by disputes over a range of obscure points of theology (see Iconoclasm and the Burger King) and the various heretical movements threatened the stability of the Empire. In his attempt to establish an orthodox form of Christianity Justinian defunded and closed a range of monasteries and institutions that refused to fall in line. Faced with charges of heresy many scholars fled east and took refuge in territory controlled by the Persian Sassanid Empire. They took with them a large volume of Greek and Roman manuscripts including works by Aristotle, Archimedes, Euclid and Ptolemy and, of course, Hippocrates and Galen.

Justinian also restructured the taxation system and embarked on a large program of public works that included the domed megachurch of Hagia Sophia. Less spectacular, but much more important in the long run, was the establishment of a network of ‘xenones’ – purpose-built hospitals run by the church so that the urban poor could have access to basic amenities. The State also established poorhouses (ptocheia) and homes for the aged (gerokomeia). Previously, in both Roman and Greek societies, there had been no real attempt to provide organised care for vulnerable members of society. Instead widows and orphans and the sick had to rely on charity from wealthy citizens and the Cura Annonae (grain dole) provided by the emperor and distributed from the Temple of Ceres. Under Justinian many of the institutions that would form the basis of modern welfare systems started to take shape. Historian Chris Gilleard provides an insight into what conditions were like in one Byzantine gerokomeia.

“the care that they offered appears to have been of a remarkably high standard, as compared with that provided in medieval Western Europe. In one institution that accommodated 24 frail, aged persons, care was provided by six male nurses who were to ensure that the residents had a light but nourishing diet of olive oil, wine, bread and cheese, that they had sufficient wood for fuel, and that they received an appropriate ‘ allowance ’ for their clothing and other expenses. The regimes formalised by the typikon provided regular baths and clean bedding, and if one of the residents became ill, they were transferred to the adjoining hospital, where they received treatment from the attending physicians. “

Likewise medicine in the ancient world had mainly been reserved for those who could afford personal physicians or attend healing temples like the Asclepieums. Wealthy citizens generally employed people with some medical training to serve as part of their household staff but the level of experience and education amongst these practitioners varied greatly. Following Justinian’s reforms physicians had to undergo a lengthy practical apprenticeship followed by standardised examinations and certification. Qualified physicians were encouraged to practise at the xenones and Justinian’s measures prompted a shift away from private practise towards a crude form of community healthcare.


The Plague of Justinian

In 541 an epidemic broke out in the port city of Pelusium on the Nile delta. Initially, the threat posed by the disease seemed distant but, as it spread into Syria and made its way north, Egypt’s epidemic became a full-blown pandemic. Grim rumours reached towns and cities ahead of the contagion but nothing prepared people for what they experienced when it arrived. Byzantine chroniclers had never encountered anything like the disease that swept across the Empire in the 6th century but their descriptions of its symptoms have allowed modern epidemiologists to identify the pathogen with some degree of confidence – the bacterium Yeresinia pestis, now simply known as ‘plague’.

Plague infections are terrifyingly aggressive and manifest themselves in several different ways. The most common form is contracted though flea bites and attacks the lymphatic system – creating painful swollen ‘buboes’ in the thighs, neck, groin and armpits. A second form – pneumonic plague – is carried by airborne droplets and infects the lungs and respiratory system. The rarest form – septicemic plague – occurs when the bacteria directly infects the bloodstream. All three forms are incredibly virulent and the infection generally runs its course in only a few days. Left untreated bubonic plague has a case fatality rate of roughly 50%. The pneumonic and septicemic forms are almost always always fatal.

One of the main records we have of the Plague of Justinian are fragments of a chronicle written by the monophysite Bishop John of Ephesus. John was a native of Amida (modern Diyarbakr in Turkey) and had been sent to Palestine to enforce Justinian’s laws against heresy when the epidemic reached the Holy Land. Sometime around 542 AD he traveled north to Constantinople and witnessed the plague wreak havoc on the outlying provinces and the capital itself.

John starts his chronicle with a particularly chilling line;

“The mercy of God showed itself everywhere towards the poor, for they died first…”

He goes on to describe the effects of the plague in almost apocalyptic terms. Entire towns were emptied of people. Corpses lay beside roads and in fields and stray cattle wandered the hills. Merchant sailors died en route to their destinations and their ships were left drifting on the ocean. In the towns and cities people collapsed at worksites and bathhouses and in the streets. Farmers stopped bringing produce to market and all commerce ground to a halt while the price of basic goods spiralled out of control. Looting and robbery became commonplace and those fleeing the towns and villages ended up accelerating the spread of the plague.

At the height of the pandemic in Constantinople the only thing that brought people out of their homes was the necessity of removing bodies – most of which were dumped unceremoniously in the harbour. Eventually the task overwhelmed the volunteers and the Emperor appointed a referendarius (a high official) named Theodore to pay and equip work parties for the task. Mass graves were dug on the northern side of the harbour and, when they were filled, the bodies were dumped into the towers of the city walls. While some volunteered out of a sense of duty others demanded fees that reflected the risks they were taking and John records that stretcher-bears could earn a small fortune for a days work. Officials posted at the gatehouse and the entrances to the harbour initially tried to record the number of plague victims but, at some stage, even that became impossible.

“Those who counted, having reached the number of 230,000 and seeing that the dead were innumerable, gave up reckoning and from then on the corpses were brought out without being counted.”

John goes on to explain that anyone who ventured out to bury the dead or attend to the sick hung a sign over their shoulder that listed their name, their father’s name and the neighbourhood they belonged to along with instructions to notify their family if they died. That way they might receive the proper funeral rites and burial that assured them a place in the afterlife.

Throughout his account John refers to the plague as a ‘chastisement’ from God but never ventures to guess what sin has provoked such a reaction (“His righteous judgements which cannot be understood, nor comprehended, by human beings”). Despite the trust he places in god he struggles to imagine a future for himself or the Empire that he belongs to. Even recording the events seems futile given the scale of the disaster.

“Thus when I, a wretch, wanted to include these matters in a record of history, my thoughts were seized many times by stupor, and for many reasons I planned to omit it, firstly because all mouths and tongues are insufficient to relate it, and moreover because even if there could be found such that would record (at least) a little from among the multitude (of matters), what use would it be, when the entire world was tottering and reaching its dissolution and the length of generations was cut short? And for whom, would he who wrote, be writing?”

Although John tells us that the poor were the first victims of the plague it quickly swept through the rest of Byzantine society. Justinian himself contracted the plague but managed to survive. His empire, on the other hand, never fully recovered. Before 541, Justinian’s generals had reconquered much of the western part of the Roman Empire from the Goths, the Vandals and other tribal coalitions. After 541 it was a challenge just to hold on to the immediate territory around Constantinople. The Emperor struggled to fill the ranks of his armies, extract taxes and pay the units that manned the frontiers. The western territories quickly began to revolt. The plague reached Rome in 543, and was recorded in Britain in 544. A second wave broke out again in Constantinople in 558 and further waves followed. It’s estimated that between 541 and 586 AD the Plague of Justinian wiped out roughly a quarter of the population of the Eastern Mediterranean – more than 25,000,000 people.

Throughout the pandemic physicians continued to subscribe to Galen’s theories of bodily humours and gaseous miasmas but, at the same time, it was obvious that the treatments and preventative measures they prescribed had very little effect. In most accounts of the plague physicians are only mentioned to illustrate the futility of human intervention. In his History of the Persian War the writer Procopius tells us that:

“Moreover I am able to declare this, that the most illustrious physicians predicted that many would die, who unexpectedly escaped entirely from suffering shortly afterwards, and that they declared that many would be saved, who were destined to be carried off almost immediately. So it was that in this disease there was no cause which came within the province of human reasoning; for in all cases the issue tended to be something unaccountable. …And again, methods of treatment showed different results with different patients. Indeed the whole matter may be stated thus, that no device was discovered by man to save himself, so that either by taking precautions he should not suffer, or that when the malady had assailed him he should get the better of it; but suffering came without warning and recovery was due to no external cause.”

Many features of Justinian’s Plague defied conventional wisdom at the time. Most contagious diseases familiar to the classical world were seasonal to some extent – they flared up during the warmer months and subsided temporarily over winter. Justinian’s Plague didn’t follow that pattern because, although the bubonic form of the disease is tied to flea activity (which is limited in winter), the pneumonic form remains just as contagious all year round. A later John – the 7th century Archbishop Of Thessalonica – mentioned another inexplicable aspect of the plague in his Hagiography of St. Demetrius.

“Neither babies, nor women, nor the flower of youth, nor men of arm-bearing and city-service age were spared from the disease: only the elderly escaped. God had desired thus so that no one would be able to claim that the epidemic had been a natural phenomenon caused by the corruption of the air, and not a divine punishment.”

From our modern vantage point we can assume that an earlier outbreak might have conferred some level of immunity on Thessalonica’s older generation but, from where John sat, there was no point looking for a natural explanation.

Despite declarations that the plague was God’s punishment we can still see some awareness of the mechanism of contagion in accounts from the time. John of Ephesus wrote that plague ‘crossed the sea’ [i.e., from Alexandria] to Palestine and the region of Jerusalem and Procopius observed the tendency for the plague to spread from coastal settlements to inland communities (‘this disease always took its start from the coast and, from there, went up to the interior’).

Another hagiography – this time by a disciple of St. Symeon – even charted the outbreak at a local level in the city of Antioch. He described how the plague spread from one district of the city to another and that one section of the city escaped the epidemic altogether.

Despite the Christian belief that plague was a ‘chastisement’ the general population clearly felt that it was possible to outrun god’s wrath. Those that had the means fled urban centres and confined themselves to rural estates and, over and over, the sources tell us that panicked residents abandoned entire towns and villages. A popular saying, attributed to Galen, instructed people threatened by pestilence to ‘fly quickly, go far, return slowly’ (Cito, longe fugas et tarde redeas).

Charting the collapse of the Byzantine Empire from its height  under Justinian in the 6th century to its last enclaves in the 14th century.

The End of Antiquity and the Rise of Islam

Renewed outbreaks of the Plague of Justinian continued for the next two centuries at intervals ranging between six and twenty years. At the same time a succession of Byzantine Emperors perpetuated a grinding war of attrition against their Persian Sassanid neighbours. During that time a number different faiths competed for influence in Europe and the Middle-East. Various forms of Christianity dominated the regions formerly governed by the Roman Empire but pagan traditions persisted amongst the ‘barbarian’ tribes of Northern Europe and Britain.

Jewish communities had also established themselves in coastal cities around the Mediterranean- the result of their expulsion from Palestine during the Jewish-Roman wars of the first century. The Israelites would end up having the last laugh, however, as they watched Roman and Egyptian paganism give way to the growing cult of Christianity. Pagan ceremonies and feast days were soon supplanted by Christian ‘Holy Days’ while lesser deities were replaced by saints and martyrs with corresponding powers. Christmas Day replaced the Roman winter solstice while All Soul’s Day (later Halloween) was moved to coincide with the Gaelic festival of Samhain. Likewise the name and the date of Easter appears to have been derived from an earlier spring festival dedicated to the Germanic goddess Ēostre.

In Persia the ancient monotheistic religion of Zoroastrianism underwent a dramatic revival starting in the 3rd century AD. The Persian Sassanids promoted the religion and established hundreds of fire temples dedicated to their god Ahura Mazda. At the same time a Persian mystic named Mani declared himself a prophet and founded his own religion combining elements of Christian, Zoroastrian and Buddhist traditions. He was executed for heresy by the Sassanid King Bahram I in 274 AD but his followers carried on his teachings and established themselves as far afield as Britain and China.

The various religious traditions addressed epidemic disease in different ways but few provided any practical advice until the advent of Islam. In the early 7th century an orphan belonging to a small tribe near Mecca called the Quraysh declared himself a prophet and founded a new religion. Islam (roughly meaning ‘submission’) took inspiration from the old testament and offered a much more prescriptive take on the god of Abraham. Thanks in part to some spectacular military victories during Muhammad’s lifetime the new faith quickly established itself among the Arab tribes and was adopted by neighbouring ethnic groups as the power of the early Caliphate grew.

Two of Islam’s central tenets may have indirectly provided Muslims with some insurance against contagious disease. The first was the obligation placed on the faithful to provide some portion of their income as zakāt (‘alms’) to the poor and needy. These funds were used by the early Caliphate to establish a robust welfare system that helped mitigate the effect of plagues, draughts and other natural disasters.

Welfare programs may seem somewhat removed from the treatment of epidemic disease but basic improvements to housing and sanitation go a long way toward reducing the impact of disease. Recent research has attributed the modern increase in life expectancy to what are sometimes referred to as the ‘social determinants of health’ – living conditions, hygiene and nutrition – rather than advances in medicine itself.

As the Caliphate expanded welfare provisions were extended to non-muslim subjects of the State (known in Arabic as the ḏimmah) and the zakāt helped blunt the impact of disease by ensuring that most people could meet their basic needs. Starting under the Caliph Umar salaries were paid to the unemployed as well as to the families of soldiers. The various ministries established by Umar kept meticulous records of their expenditure and, at one stage, the Caliphate’s military department had 700,000 individuals listed in their State benefits records. Provision was also made for war widows with one woman receiving 200 dirhams a month for each of her four sons who had been killed in the Caliph’s campaigns. Even childcare was underwritten by the State with parents asked to bring newborns to provincial welfare offices to register their children and claim the benefits.

Another core practise of Islam – ritual purification – may also have helped slow the spread of infectious disease. Islamic law requires Muslims to pray five times a day but each prayer should also be preceded by a ritual known as wuḍūʾ where the face, arms, and feet are cleansed with water. It’s difficult to measure the relationship between infection rates and hand washing rituals like wuḍūʾ but it seems likely that Islamic hygiene practises did offer some protection.

Public hygiene was also policed by Islamic officials known as Muhtasib who ensured that weights and measures were calibrated and business was conducted in accordance with the law of sharia. As government inspectors the Muhtasib made sure that food in marketplaces was sanitary and monitored the quality of the water supply. As time went on the responsibilities of the Muhtasib expanded to include licensing for those in the medical profession. They administered the Hippocratic oath and supervised pharmacists and apothecaries to ensure that their medicines were not diluted or contaminated.

The fortress of Nahavand near modern day Hamadan as imagine by the 19th century artist and archeologist Eugène Flandin.

The Plague of Amwas

While apocalyptic prophesies may have helped Christian communities reckon with their own mortality they didn’t provide much guidance for how to cope with the day-to-day reality of epidemic disease. Muslims, on the other hand, had some assistance from their scripture. Muhammad had lived at a time when the Plague of Justininan was still wreaking havoc across the known world and, while Christians were left wondering what Jesus would do, the followers of Muhammad could turn to the advice of the hadiths. Much like the Christian gospels the hadiths offer an account of Muhammad’s life by those closest to him at the time. They sit outside the Quran but are used as a guide for how muslims should conduct themselves.

The Sahih al-Bukhari hadith gives an account of a debate-by-correspondence between the Caliph Umar and his senior commander in the Byzantine-Arab wars Abu Ubaidah. When Justinian’s plague broke out in Amwas (Imwas in modern Israel) Umar ordered Abu Ubaidah to abandon his army and return to Medina. Out of loyalty to his men Abu Ubaidah refused – invoking Muhammad’s instructions;

“If you hear of an outbreak of plague in a land, do not enter it; but if the plague breaks out in a place while you are in it, do not leave that place.”

True to his convictions Abu Ubaidah died of the plague in 639 AD along with roughly 25,000 of his followers. As the epidemic spread many Christians in Syria fled or succumbed to the plague – leading to what historians obliquely refer to as a period of ‘demographic decline’. Up until that point the Caliphate had raised revenue in their conquered territories through a poll tax on the dhimma but, after the plague of Amwas, there were few locals left to prop up the economy. Rather than give up the territory Umar encouraged Arab tribespeople to move west and settle in Syria.

Like Cyprian early Muslim scholars also tried to spin plague mortality as something to aspire to rather than something to fear. While Christianity struggled for centuries to reconcile the contradiction between a loving god and sudden bouts of indiscriminate death the hadiths provided an immediate, if not particularly satisfying, answer. When the prophet’s wife Aisha asked whether plague was a punishment from god Muhammad replied.

“Plague was a punishment which Allah used to send on whom He wished, but Allah made it a blessing for the believers. None (among the believers) remains patient in a land in which plague has broken out and considers that nothing will befall him except what Allah has ordained for him, but that Allah will grant him a reward similar to that of a martyr.”

As well as taking over most of Egypt and Syria Umar’s forces invaded the Persian Sassanid Empire. The Sassanids had been worn down by fighting with the Byzantines and depleted by the plague (known in Persia as the Plague of Shērōē after the Sassanid King). Shērōē had partially converted to Christianity but the nuances of the religion seem to have escaped him because he ascended to the throne by murdering most of his immediate family. Shērōē died of the plague only a few months into his reign. He was succeeded by his eight-year-old son Ardashir III who was quickly overthrown and killed in a coup by the Zoroastrian priesthood. Years of civil war followed and when Umar began his campaign against the Sassanids the Empire was still deeply divided and poorly led.

Even then the Sassanids should have easily repelled the invasion. On paper they outnumbered the Arab armies by a wide margin. Instead Umar’s forces dealt a series of stunning defeats to the Persians beginning with the Battle of Nahavand in 642 AD. By the end of the decade all organised opposition to the Arab invaders had collapsed and Persia had become a client state to the Caliphate. By annexing Mesopotamia the Caliphate also inherited the small community of Nestorian Christians and other exiles that had fled Byzantine persecution.

The centre of Sassanid scholarship and the main hub of Byzantium’s ex-pat community was the Academy of Gondishapur in modern-day Khuzestan, Iran. Starting in the early 6th century classical texts had been translated from Greek and Syriac into the local Pahlavi language. The academy also compiled and translated ancient Persian medical treatises like the Vendidad (part of Zoroastrian scripture) as well as Sanskrit works like the Ayurveda. After Umar’s Arab armies took over Persia the Caliphate sponsored a vast expansion of the translation program – this time to Arabic – eventually leading to the establishment of the famous Khizanat Kutub al-Hikma (“Storehouse of the Books of Wisdom”) in Baghdad.

By the time the Plague of Justinian came to an end the cultural and political geography of the western world had been completely transformed. The vast loss of life caused by the plague created a vacuum that pulled in new tribes and peoples from beyond the frontiers of the old empires. These mass migrations displaced cultures and languages connected to the very earliest human settlements in Europe and brought more and more people in contact with the new religions of the Byzantines and the Arabs.

By the 8th century most societies in southern Europe and the Middle East had abandoned their ancestral pagan traditions in favour of some form of monotheism. For the first time ever Gaels, Britons, Franks, Goths, Greeks, Armenians and Georgians and a host of other peoples all shared the same basic belief system. Likewise Arabs, Persians, Syrians, Egyptians, Berbers, Egyptians and Ethiopians found themselves united under Islam and connected by the Arabic language. The dominance of these two faiths set the stage for the contests that would play out over the next millenia.

Amid the upheaval and death a small community of exiles from the Byzantine Empire managed to preserve and expand upon Greek and Roman philosophy. The translation program carried out in Gondishapur and Baghdad formed the basis for a revolution in science and medicine that would ultimately help reveal the mechanisms of contagious disease.


The second half of this piece on historical pandemics will examine the Islamic Golden Age, the Black Death and the first concerted efforts to contest the Galenic theories of contagious disease.

Kyle Harper – Pandemics and Passages to Late Antiquity
Guido Alfani, Tommy E. Murphy – Plague and Lethal Epidemics in the Pre-Industrial World
Roger Pearse blog – John of Ephesus describes the Justinianic plague
John Atkinson – The Plague of 542: Not the birth of the clinic
Demetrios J. Constantelos – Byzantine Philanthropy – Part II
Peter Lampe – Social welfare in the Greco-Roman world as a background for Early Christian practice
Basem A Khalil – Modern Insights into the Policies affecting Public Health in the Islamic Caliphate (622CE – 1258CE)
Evagrius Scholasticus – Ecclesiastical History
Chris Gilleard – Old age in Byzantine society
Lester K. Little – Plague and the End of Antiquity
John B. West – Galen and the beginnings of Western physiology
John Scarborough – Galen and the Gladiators
Cassius Dio – Roman History – Thucydides on the Plague
Elizabeth Kolbert – Pandemics and the Shape of Human History
Sarah K. Yeomans – The Antonine Plague and the Spread of Christianity
Christopher Jon Elliott – Galen, Rome and the Second Sophistic
Michael Cook – How and Why Muhammad Made a Difference
Caroline Stone – The Muhtasib
Jennie Naidoo, Jane Wills – Foundations for Health Promotion
Christopher Sawyer – Confronting the Flood: Byzantine Reactions to the Rise of Islam


Richard Pendavingh

Photographer, designer and weekend historian. Editor of The Unravel. Writes about design, tech, history and anthropology.

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