The Rise and Fall of the Bubonic Plague: A Historical Perspective

Throughout human history, different infectious diseases have taken the mantle of the “most deadly disease” infecting humans. In the past century alone, the human population has experienced many pandemics, such as COVID, HIV, and various influenza outbreaks. Some of these diseases have lasted for centuries and still persist today, like tuberculosis. Others, however, are often considered consigned to the history books. Before the 20th century, the most deadly disease in Europe and surrounding areas was the bubonic plague. Three major pandemics of this disease have occurred in the past 1,500 years.

The first major outbreak of the bubonic plague occurred from the fifth to the seventh century, killing about 15 million people in the Mediterranean basin and heavily affecting the Byzantine, Sasanian, and Roman empires. The second outbreak, known as the Black Death, ravaged 14th-century Europe, claiming over 50 million lives, approximately 50% of the entire European population. The third wave of this pandemic occurred globally in the 19th and 20th centuries, resulting in a further 30 million deaths worldwide, with many of these occurring in China and India. Despite a significant drop in cases from the 1960s onwards, the bubonic plague is not often considered a modern disease. However, a recent case reported in the US has renewed interest in this once-devastating disease.

The bubonic plague, caused by the bacterium Yersinia pestis, has three main forms: pneumonic, septicemic, and bubonic. Each form targets a different part of the body as the primary site of infection. Bubonic plague is mainly spread by fleas that live on small animals, particularly rodents like rats, which serve as reservoirs for the bacteria. These rodents can pass the bacteria to humans through flea bites, causing infection in the lymph nodes. The main symptom of bubonic plague is swollen lymph nodes, known as buboes, which may rupture and lead to tissue death. Other symptoms include fever, headaches, and vomiting, with the pathogen potentially spreading to other parts of the body, resulting in pneumonic or septicemic plague.

Why was the bubonic plague so prominent hundreds of years ago but rarely heard of today? The key lies in the combination of the flea vector, rodent reservoir, and Yersinia pestis bacteria occurring in close contact with humans. Before the 19th century, diseases were primarily believed to be spread by miasmas, or noxious forms of air. It was only after the 1880s that people realized microscopic organisms transmitted between humans, animals, and the environment can cause diseases. Improvements in sanitation, separating rodents from humans, and the discovery of antibiotics, notably fluoroquinolones from the 1960s onward, have significantly reduced cases of the plague.

Although the bubonic plague is no longer as prevalent as it once was, cases still occur in specific hotspots, mainly in Asia, Africa, and South America. Countries like the Democratic Republic of Congo, Peru, and Madagascar have seen the most cases, with Madagascar experiencing major outbreaks in recent years. Due to the complex transmission network involving fleas, rodents, and humans, the plague may never be eradicated entirely. However, proper handling of animals, separation of natural reservoirs and humans, and rapid and effective treatment have been instrumental in decreasing the number of plague cases each year. With continued efforts, there is hope for negligible case numbers in the future, marking a significant decline in the impact of this historical deadly disease.