Secrets of the Great Plague:
Paths of Spread
Automatic translate
The Black Death, which devastated much of the world in the mid-14th century, is considered one of the deadliest pandemics in human history. This catastrophe claimed the lives of tens of millions of people, significantly changing the demographic and socio-economic picture of entire regions. Modern research allows us to uncover many secrets about the origin, mechanisms and routes of spread of this disease, which for a long time remained the subject of speculation and conjecture.
The period from 1347 to 1351 was characterized by the rapid spread of the epidemic across Eurasia and North Africa. The bacterium Yersinia pestis, responsible for the bubonic plague, was transmitted through the bites of fleas that parasitized rodents, creating a complex chain of infection. Historical evidence and modern scientific data allow us to reconstruct the routes and mechanisms of the Black Death, as well as to understand the factors that determined its catastrophic scale.
2 Biological mechanism of dissemination
3 Pathways of distribution on a global scale
4 Spread in Europe
5 Consequences of the epidemic
6 Historical recurrences of plague epidemics
7 Modern scientific knowledge about the spread of plague
8 Lessons of the Black Death for the Modern World
Origin of the Black Death
The origins of the Black Death have long been one of the great mysteries of historical epidemiology. Modern research suggests that the pandemic that devastated medieval Europe originated in Asia. Documentary evidence and genetic studies confirm that the first significant outbreaks of the disease were noted in China and Central Asia in the 1330s.
The Origin of the Epidemic in Asia
According to historical sources, the first major outbreaks of the plague occurred in China around the 1330s. The History of the Ming Dynasty mentions that the first wave of the plague hit China in 1344, three years before it arrived in Europe. This period coincided with the Mongol rule of China under the Yuan Dynasty, when the country experienced a series of natural disasters, including droughts, floods, and subsequent famine.
It was from this source of great famine that the plague began. Millions died in Hebei Province. The spread of the disease and trade went hand in hand. Fleas carrying the deadly bacterium Yersinia pestis were carried by rats along the main trade route, the Silk Road, infecting everyone in their path and eventually reaching Crimea, from where the disease was carried to mainland Europe via merchant ships.
New research into the origins of the plague
Recent scientific research has made a significant contribution to understanding the geographical origins of the Black Death. In 2022, European scientists from the University of Stirling (Scotland) and the University of Tübingen (Germany) conducted a DNA analysis of human remains from burials near Lake Issyk-Kul, located in what is now Kyrgyzstan.
The researchers turned their attention to the area after noticing a sharp increase in deaths in the area in 1338-1339. Analysis of teeth from burials revealed traces of the plague bacterium Yersinia pestis in the remains of three people. This discovery suggests that the initial outbreak of the plague, which later spread to much of the Old World, occurred in this region of Central Asia.
Genetic studies have shown that the strain of Yersinia pestis that caused the Black Death is the ancestor of all known modern strains of the bacterium that cause disease in humans, suggesting that the origins of modern plague epidemics can be traced back to the medieval period and specifically to this pandemic.
Biological mechanism of dissemination
Understanding the biological mechanism of plague spread is the key to unraveling the mystery of its rapid spread in the mid-14th century. Medical knowledge of that time was insufficient to effectively combat the epidemic, and only modern science has made it possible to reveal the nature of the pathogen and its transmission routes.
Yersinia pestis bacteria and its features
The causative agent of the plague, the bacterium Yersinia pestis, was discovered only in 1894 by the French bacteriologist Alexandre Yersin, after whom it was named. Before this discovery, the causes of the emergence and spread of the plague remained a mystery and the subject of much speculation.
Yersinia pestis has a number of properties that make it an extremely dangerous pathogen. The bacterium is capable of rapidly multiplying in the host organism and causing fatal disorders of various organ systems. One of the features of Yersinia pestis is the ability to cause various forms of the disease depending on the route of infection, which played an important role in the scale of the medieval pandemic.
The life cycle of the bacteria includes stages of stay both in the body of fleas and mammals, primarily rodents. In the body of a flea, the bacteria quickly multiply and form clusters that block the insect’s digestive tract, which leads to a constant feeling of hunger in the flea and multiple attempts to suck blood.
The role of fleas and rodents in disease transmission
The main mechanism of plague spread is zoonotic transmission – from animals to humans. The main reservoirs of infection are various types of rodents, in whose bodies Yersinia pestis bacteria can exist for a long time, forming natural foci of infection.
Fleas are carriers of the bacteria between rodents, as well as from rodents to humans. When an infected flea tries to feed on blood, it regurgitates the contents of its stomach, containing a large number of bacteria, into the host’s wound. This is how the new organism is infected.
Rats, especially black rats (Rattus rattus), played a critical role in the spread of bubonic plague in medieval Europe. Living close to human habitation and traveling with cargo on merchant ships and caravans, rodents contributed to the rapid geographic spread of the infection. When rodents died en masse, fleas, having lost their usual hosts, actively migrated to humans, which led to outbreaks of the disease.
Forms of manifestation of plague in humans
Plague in humans can manifest itself in several forms, each with its own characteristics in terms of symptoms, transmission mechanisms, and lethality. Understanding these forms is important for understanding the dynamics of the spread of the Black Death.
The bubonic form is the most common and occurs when bacteria enter through the skin, usually as a result of a bite from an infected flea. The characteristic symptom of this form is the formation of buboes – inflamed and painful lymph nodes, mainly in the groin, armpit or neck area. Without treatment, the mortality rate from bubonic plague is 40-60%.
The septic form develops when bacteria enter the bloodstream directly, which leads to rapid proliferation of pathogens in the blood and severe intoxication of the body. This form is characterized by fever, chills, extreme weakness, abdominal pain, shock, and possible bleeding into the skin and internal organs. Mortality in the absence of treatment is close to 100%.
Pneumonic plague occurs when bacteria enter the respiratory tract, or as a complication of the bubonic or septicemic form when the infection spreads to the lungs. This form is particularly dangerous because it can be transmitted from person to person by airborne droplets when coughing. Symptoms include fever, headache, weakness, and rapidly progressing pneumonia with shortness of breath, chest pain, cough, and bloody sputum. Without modern treatment, the mortality rate for pneumonic plague is almost 100%.
It was the combination of different forms of plague, especially the possibility of transmission of the pneumonic form from person to person, that made the Black Death so deadly and capable of spreading quickly in the densely populated cities of medieval Europe.
Pathways of distribution on a global scale
The Black Death demonstrated how interconnected the medieval world was through trade routes and how quickly a deadly infection could spread, even in an era before modern transport. Analyzing the spread of the plague reveals the main routes and factors that determined the geographical expansion of the disease.
The Great Silk Road as a distribution channel
The Silk Road, which linked East Asia with the Mediterranean, played a critical role in the spread of the Black Death. This network of trade routes, stretching for thousands of kilometers through Central Asia and the Middle East, not only ensured the exchange of goods and ideas, but also created conditions for the movement of infectious disease pathogens.
Caravans carrying silk, spices and other goods unwittingly became carriers of infected rodents and fleas. Trading posts and caravanserais where travelers stayed facilitated contacts between people from different regions and created conditions for the spread of disease.
Statistical analysis of the geographical distribution of plague outbreaks and the location of major trade routes shows a significant correlation between them. According to research published in the scientific journal Nature, major trade routes played a dominant role in the spread of plague in pre-industrial Europe. The negative correlation between plague outbreaks and their distance from major trading ports indicates the absence of a permanent plague hotbed in the interior of Europe.
Sea trade routes and their role
While land trade routes helped spread the plague across continental Eurasia, maritime routes played a decisive role in carrying the infection across the Mediterranean to Europe and North Africa. Genoese, Venetian and other merchant ships carried not only goods but also infected rats with their fleas.
Seaports were of particular importance, serving as hubs of trade networks and gateways for the disease into new territories. Historical evidence suggests that major plague outbreaks often began in port cities, from where the infection spread inland.
The geography of the Aegean Sea, a “closed sea” with many ports located at short distances from each other, contributed to the particularly rapid spread of the plague in this region. The maritime network with standard routes to Constantinople via the Aegean Sea (Venice-Ragusa-Corfu-Methone-Koroni-Kerigo-Negroponte-Thessaloniki-Lemnos-Constantinople) or the typical route of the Venetian Armada to the Middle East via Cyprus (Venice-Ragusa-Corfu-Methone-Koroni-Candia-Rhodes-Famagusta) became the routes of spread of the disease.
Under favorable weather conditions, medieval ships in the Eastern Mediterranean could cover an average of 75 nautical miles per day. This means that in the special cases of the short-distance ports of the Aegean and Ionian Seas, the duration of the journey in Byzantine territories was shorter than the incubation period of the plague, which contributed to the rapid spread of the disease.
Spread throughout Asia
Historical reconstruction of the spread of the plague across Asia is somewhat difficult due to the smaller number of written sources compared to Europe. However, the available data allow us to trace the main directions of the disease expansion.
After its initial outbreak in Central Asia, the plague spread to China, where some estimates suggest that about half the population died. From there, the disease moved west across the steppe regions and reached India.
The spread of the plague in medieval India is not as well documented as in Europe, but surviving sources indicate that the pandemic also affected the Indian subcontinent. Ibn Battuta, an Arab traveler who visited various parts of India from 1334 to 1347, reports two epidemics, in 1335 and 1344, which were very likely outbreaks of the plague.
The first of these epidemics broke out in Warangal in 1335. Barani, a historian of the time, writes: “The Sultan arrived in Warangal, where the waba (plague) was raging. Several nobles and many others died of it.” Ibn Battuta also mentions an outbreak of the epidemic in Bidar, when Muhammad bin Tughlaq was there with his troops, noting that the epidemic destroyed half of the Sultan’s troops.
The Way to Europe and North Africa
The plague’s spread to Europe and North Africa marked a new phase in the spread of the Black Death, which proved particularly catastrophic for these regions. Historical documents make it possible to trace the routes of the disease’s spread quite accurately.
The plague reached Europe via the Black Sea port of Kaffa (modern Feodosia in Crimea), where the Genoese established a trading post. There is evidence that the Mongol troops besieging the city in 1346 used the corpses of those who died from the plague for biological warfare, catapulting them over the city walls. Although the effectiveness of such tactics is disputed by modern researchers, this episode is often cited as one of the first recorded uses of biological weapons.
After the siege was lifted, the Genoese ships left Caffa and headed for Italy, unwittingly carrying infected fleas and rats. In 1347, the plague reached Constantinople, and then spread to the Aegean islands (Lemnos and Euboea), Crete and other territories of the Byzantine Empire.
That same year, the disease reached Sicily, from where it began its deadly journey across Italy and continental Europe. The plague arrived in North Africa around the same time, spreading via maritime trade routes from the Middle East and Europe.
The speed of the plague’s spread was astonishing for its time. Less than three years passed from the first recorded cases in Crimea to the spread of most of Europe. This speed is explained by both the efficient mechanisms of infection transmission and the developed network of trade routes that connected different regions.
Spread in Europe
The European phase of the Black Death has become the most documented and studied in the history of the pandemic. Numerous chronicles, medical treatises and administrative documents of the time allow us to trace in detail the routes and chronology of the spread of the disease, as well as the reaction of society to this catastrophe.
First foci and routes of penetration
The first recorded cases of plague in Europe are associated with the arrival of Genoese ships from Caffa in the Sicilian port of Messina in October 1347. The ships arrived with many sick people on board, and soon after their arrival, an epidemic broke out in the city. The authorities in Messina attempted to stop the spread of the disease by ordering the ships to leave the port, but it was too late – the infection had taken hold in the city.
From Sicily, the plague quickly spread across mainland Italy, reaching Genoa and Venice by January 1348. Venice, as the largest trading center in medieval Europe, became an important hub for the further spread of the disease. Through Venetian trade links, the plague penetrated into the Balkans and Central Europe.
At the same time, the disease was also spreading via other sea routes. From Italian ports, the infection reached Marseilles in France, and from there it spread into France. By June 1348, the plague had reached Paris. Spain was also affected via its Mediterranean ports, and the disease reached England via the port of Weymouth in Dorset in June 1348, when a ship arrived from Gascony (a French province under English control).
Speed and scale of spread
The speed at which the plague spread across Europe was staggering. Between 1347 and 1351, the disease covered almost the entire continent, from the Mediterranean to Scandinavia and from the Atlantic coast to the Russian lands.
From England, where the plague arrived in the summer of 1348, the disease quickly spread north. By the autumn of that year, the epidemic had reached London, and by the summer of 1349 it had engulfed the entire country before dying down by December. The death rate was so high that researchers estimate that between 40% and 60% of England’s population perished.
The situation on the continent developed similarly. By 1349, the plague had spread to what is now Germany, the Netherlands, and Scandinavia. In 1351, the last outbreaks were reported in Russia. The overall mortality rate in Europe is estimated at 25-30 million people, which is about a third of the continent’s population at the time.
The speed of the plague’s spread was explained not only by its developed transport network, but also by its ability to quickly adapt to new conditions and carriers. As it moved across Europe, the plague could "switch" between different rodent species, creating new natural foci of infection.
Factors that contributed to the rapid spread
The catastrophic scale of the Black Death pandemic in Europe is explained by a combination of several factors that enhanced the natural mechanisms of the disease’s spread and made it more difficult to combat it.
One of the main factors was the high population density in medieval cities with extremely low levels of hygiene and sanitation. Overcrowding, lack of sewage, accumulation of garbage and waste created ideal conditions for the reproduction of rats - the main reservoirs of the plague bacteria. Cramped dwellings, where people often lived together with domestic animals, contributed to close contact between people and carriers of infection.
Another factor was the lack of scientific knowledge about the causes of the disease and effective methods of combating it. Medieval medicine, based on the concept of the “four humors,” was helpless in the face of the bubonic plague. The proposed treatments, such as bloodletting, often only weakened patients and reduced their resistance to infection.
Social reactions to the epidemic also contributed to its spread. Many wealthy citizens and nobles fled infected cities, unwittingly carrying the infection to previously unaffected areas. Fear of infection led to refusal to help the sick, which worsened their condition and increased the mortality rate.
We should not forget about the religious practices of the time. Mass prayers, processions, and pilgrimages organized as a means of combating “divine punishment” often led to even greater crowding and increased transmission. Some religious groups, such as the flagellants, traveled from city to city, performing rituals of public penance, which also contributed to the geographical spread of the disease.
Finally, the climate conditions in Europe in the mid-14th century may also have played a role. The period 1300-1400 was characterized by a cold spell known as the Little Ice Age. This may have led to rodents crowding into human dwellings in search of warmth and food, increasing the likelihood of contact with humans.
Consequences of the epidemic
The Black Death had a profound and lasting impact on all aspects of medieval society. Its effects went far beyond immediate mortality and encompassed demographic, economic, social, and cultural changes that shaped Europe for centuries to come.
Demographic changes
The most obvious consequence of the Black Death was the massive demographic losses. According to various estimates, between 25 and 50 million people died in Europe, which was between a third and a half of the continent’s population. In some cities and regions, the losses were even higher – up to 70-80% of the population.
These demographic changes were long-term. The population of Europe did not reach the level of the 1340s until the beginning of the 16th century, that is, 150 years after the end of the epidemic. The decline in population led to the abandonment of many rural areas, the disappearance of small villages and a change in the structure of settlements.
The plague affected all levels of society, but its impact was uneven. Mortality was particularly high among the urban poor, who lived in the most unsanitary conditions and were unable to flee the infected cities. The clergy also suffered heavy losses due to their duties in caring for the sick and performing funeral rites.
Socio-economic consequences
The demographic crisis caused profound changes in the socio-economic structure of medieval Europe. The reduction of the workforce led to an increase in wages and an improvement in the situation of the surviving peasants and artisans. Landowners, faced with a shortage of labor, were forced to offer more favorable working conditions and reduce feudal duties.
These changes met with resistance from the ruling classes. In England, for example, in 1351 a law was passed requiring wages to be returned to pre-pandemic levels. Such measures caused discontent among the lower classes and were one of the causes of the Peasants’ Revolt of 1381.
In the long term, the economic consequences of the plague contributed to the undermining of the feudal system and the acceleration of the transition to capitalist relations. Changes occurred in the structure of land ownership, the number of large aristocratic estates decreased, and the number of small and medium-sized farms increased. In the cities, the mobility of the workforce increased, and crafts and trade developed.
The Black Death had a profound impact on international trade, temporarily disrupting established trade routes and connections. However, in the long term, it led to the search for new trade routes and stimulated the development of seafaring, which indirectly contributed to the Age of Discovery.
Changes in medical concepts and practices
The failure of traditional medicine to cope with the plague epidemic led to some changes in medical beliefs and practices. Although the miasma theory (the idea that diseases were caused by “bad air” or poisonous fumes) remained dominant, other approaches began to develop.
Some doctors of the time speculated about the contagious nature of the plague and proposed measures reminiscent of modern quarantine principles. Special sanitary councils responsible for combating epidemics began to be created in the Italian city-states. The practice of isolating arriving ships for 40 days was introduced (hence the term “quarantine”, from the Italian “quaranta giorni” – “forty days”).
Special hospitals for plague patients appeared – infirmaries, which were located outside the city walls. Protective suits were developed for doctors visiting plague patients, including a long cloak, gloves and a characteristic mask with a “beak” filled with aromatic herbs, which were believed to purify the inhaled air.
Although these measures were not based on a scientific understanding of the nature of the disease, some of them were relatively effective and laid the foundations for the development of public health in subsequent centuries.
Historical recurrences of plague epidemics
After the first catastrophic wave of the Black Death in 1347-1351, the plague did not disappear from Europe, but continued to periodically return in the form of local and regional outbreaks until the 18th century. These repeated epidemics had their own characteristics and consequences, less extensive, but still significant.
The second and third pandemics
History has recorded three great global plague pandemics. The first, known as the Plague of Justinian, began in 541 and swept across the Mediterranean region, killing an estimated 40 million people. The second pandemic — the Black Death of the 14th century and its subsequent outbreaks — lasted until virtually the end of the 17th century. The third pandemic began in 1894 in China and spread to every continent, lasting until the mid-20th century.
After the main wave of the Black Death, the plague returned to Europe many times. A second major wave, known as the "Children’s Plague" because of its high mortality rate among children, swept across Europe in 1361-1362, killing about 20% of the population.
In subsequent centuries, the plague did not reach the same scale as the initial epidemic, but local outbreaks occurred regularly. Among the most famous was the Great Plague of London in 1665-1666, which killed about 100,000 residents of the city, which was about a quarter of London’s population at the time.
The third plague pandemic, which began in China in the late 19th century, coincided with the development of modern bacteriology, which made it possible to identify the pathogen and develop methods to combat it. The pandemic spread around the world via seaports, reaching India, Africa, America, and Australia. It hit India particularly hard, killing about 10 million people.
Local outbreaks in different regions
After the main wave of the Black Death, local outbreaks of plague became a regular occurrence in Europe and elsewhere, particularly in large cities and ports where conditions favoured the spread of infection.
In the Byzantine Empire, the plague returned many times after the first wave of 1347-48. Constantinople, as the main trading center, suffered from the disease most often, experiencing new outbreaks on average every 11.1 years. According to historical data, the plague visited the city in 1347, 1361-1364, 1379-1380, 1386, 1391, 1397, 1403, 1409-1410, 1421-1422, 1431, 1435, 1438, 1441, 1448.
In the Ottoman Empire, Istanbul (former Constantinople) also suffered from epidemics on numerous occasions. For example, in 1466, the capital of the empire was struck by a terrible plague, which killed about 600 people daily. During this epidemic, Sultan Mehmed II the Conqueror, who had returned from a military campaign, was forced to wait out the end of the outbreak in the Macedonian mountains. Ten years later, Istanbul was hit by another wave of the epidemic, and the Sultan’s court temporarily moved to the Balkan Mountains.
In Russia, a significant outbreak of plague occurred in 1654-1655. The disease was brought to the capital of the Russian state from Persia or Crimea and quickly spread throughout the country. In the summer of 1654, when the number of victims among the inhabitants began to be counted in the thousands, the Tsar’s court, boyars and wealthy citizens fled from Moscow, which contributed to the spread of the infection throughout the state. According to researchers, from 25 thousand to 700 thousand people died in this epidemic out of a population of seven million people in the Russian state.
In India, according to historical sources, there were several serious outbreaks of plague during the reign of Jahangir (1605-1627). In the tenth year of his reign (1615-1616), bubonic plague appeared in the Parganas of Punjab, gradually spreading to the city of Lahore, and from there it covered the Doab region up to the outskirts of Delhi. In 1617, when Jahangir was in the village of Barasinor in Gujarat, he received information about an outbreak of plague in Kashmir.
Local outbreaks of the plague continued into the 18th and 19th centuries, although their scale and frequency gradually diminished. The last major epidemic in Europe occurred in Marseille in 1720 – 22. In Russia, the last significant outbreak was recorded in Moscow in 1770 – 72, known as the Plague Riot.
Modern scientific knowledge about the spread of plague
Progress in microbiology, epidemiology, genetics and other sciences has significantly deepened our understanding of the mechanisms of plague spread and developed effective methods of combating this disease. Modern research not only sheds light on historical epidemics, but also helps control natural foci of infection that still exist today.
Genetic studies of the pathogen
The decoding of the Yersinia pestis genome was an important step in understanding the evolution and spread of the plague pathogen. Genetic studies have confirmed that this particular bacterium caused the historical Black Death and have traced its origins and evolutionary path.
An analysis of ancient DNA extracted from the remains of plague victims from different periods in history has established that all known strains of Yersinia pestis that cause disease in humans are descended from the strain responsible for the Black Death pandemic of the 14th century. This supports the hypothesis that modern plague outbreaks have the same origins as the medieval pandemic.
Phylogenetic analysis of 17 Yersinia isolates from global sources suggests that the plague-causing bacterium originated in or near China and was subsequently transmitted via various routes, such as the Silk Road to West Asia and Africa, resulting in pandemics.
Genetic studies have also revealed that some changes in the Yersinia pestis genome over hundreds of years of evolution may have influenced the bacterium’s virulence and transmission patterns. This may explain why different historical plague waves may have had different patterns of spread and mortality.
Modern understanding of epidemic mechanisms
Modern science has made significant advances in understanding the complex interactions between the plague pathogen, its vectors, reservoirs and humans, allowing more effective prevention and control of outbreaks.
Studies have shown that Yersinia pestis circulates in natural foci among various species of rodents and their fleas. There are about 200 species of rodents in the world that are susceptible to plague, which creates a vast ecological niche for the preservation of the bacterium in nature. Natural foci of plague currently exist in various regions of the world, including Central Asia, Africa, South and North America.
There are two main types of plague foci. The first are those in which wild rodents are the primary reservoir of infection. In the second type, wild rodents are secondarily involved in the infectious process, becoming infected through contact with infected animals of other species. This understanding of plague ecology is important for developing disease control strategies.
Modern plague epidemiology takes into account many factors that influence the occurrence and spread of outbreaks: climatic conditions that affect rodent and flea populations; changes in ecological systems; migrations of animals and people; socio-economic factors that influence contacts between people and reservoirs of infection.
It is recognized that plague can take various forms, each with its own transmission characteristics: the bubonic form, caused by flea bites; the septicemic form, which develops when bacteria enter the bloodstream directly; the pulmonary form, which occurs when infected droplets are inhaled and is especially dangerous due to the possibility of transmission from person to person.
The incubation period of pneumonic plague, the most contagious form, is usually 1-3 days (maximum 6 days), which is important for quarantine measures. A person who has been in contact with infected droplets more than 7 days ago and remains healthy is extremely unlikely to develop the infection.
Modern methods of plague control include early detection and treatment of cases with antibiotics, prophylactic antibiotic therapy for contacts, vaccination of the population in endemic areas, rodent and flea control, and quarantine measures during outbreaks. Thanks to this set of measures, despite the preservation of natural foci of infection, large-scale plague epidemics in the modern world are practically excluded.
Lessons of the Black Death for the Modern World
The Black Death pandemic, despite occurring many centuries ago, contains valuable lessons for modern society, especially in the context of combating new infectious threats. Analyzing historical experience can help develop more effective strategies for preventing and controlling epidemics.
The main lesson is in understanding humanity’s global interconnectedness. The Black Death demonstrated how disease could spread throughout the known world, even with medieval transportation systems. In the modern era, with the rise of international travel and mass tourism, infectious diseases can spread even faster.
The story of the Black Death highlights the importance of early detection and response to disease outbreaks. In the 14th century, a lack of understanding of the causes of the disease and a delayed government response led to catastrophic consequences. Today, global surveillance systems and rapid response protocols aim to prevent similar scenarios.
The pandemic has shown the importance of a science-based approach to combating epidemics. Medieval methods based on superstition and misconceptions about the nature of the disease were ineffective. A modern scientific approach, including rapid identification of pathogens, understanding their transmission mechanisms, and developing specific treatments and prevention methods, is the key to successful control of infectious diseases.
The Black Death also exposed social inequalities in the face of epidemics. The rich and powerful were often able to escape the worst effects by fleeing infected cities, while the poor bore a disproportionate burden of the disease. This pattern of inequality in access to health care and ability to avoid infection is also seen in modern epidemics.