You will get plenty of answers when you search for the death toll of plague - there are answers on Wikipedia and on Encyclopedia Britannica. There are nice visualizations made by the[National Geographic] (https://www.nationalgeographic.com/science/article/141025-ebola-epidemic-perspective-history-pandemic) and the[Visual Capitalist] (https://www.visualcapitalist.com/history-of-pandemics-deadliest/), and many books and scientific publication on plague will list a death toll somewhere in their introduction.

But most of these sources are just parroting each other's numbers (BBC, Reuters, etc), and then get cited by Wikipedia as a credible source ¹, and the most commonly returned answer by search engines is specific to the 1346-1351 Black Death epidemic in Europe.

That is not the question that we asked!🔗

How far could we get in answering how many people died of the plague in total? To answer that, we best split the question up in six parts:

1. The time before the three known plague pandemics,
2. The First Plague Pandemic
3. The time between the plague pandemics
4. The Second Plague Pandemic
5. The Third Pandemic
6. After the Third Pandemic.

tl;dr. We end up with an estimate of 1.5 billion people that died of the plague in total. There is a large amount of uncertainty in the geographic range and timeframe of the early plague outbreaks, as well as demography. Taking those factors into account, we end up with a range of 670 million - 4.6 billion people.

Let's get started.

---

1. The Time before the Three Plague Pandemics🔗

The first thing you need to know is that plague has been killing people for at least 5,000 years². And when you move that far back in history it becomes extremely difficult to assess how many people lived, let alone how many people died of a particular disease. However, it does look like that 5,000 years ago plague was already wrecking havock: remnants of the plague bacterium have been found across Eurasia, in a surprising large fraction of the corpses that were tested for the presence of ancient plague DNA.

Across the 751 corpses sampled for plague in ancient DNA studies that pre-date the First Plague pandemic, 45 were positive for plague! And these are not only corpses that died under suspicious circumstances (like a mass burial), but also individual graves. Given that we have little other information to go on, we will use this 6% of all-cause mortality as our source of truth from which to establish the number of people that died of plague prior to the Three Plague Pandemics.

Using the 6% all-cause mortality estimate for plague, we can leverage demography datasets like HYDE 3.2, and a rule of thumb approximation of the birth rate of 80 people per 1,000 people alive, as used in this PRB blog post on the world population, to get to a total number of people that died of plague.

That leaves two questions open. How far back in time do we assume plague killed 6% of all people, and across how large a geographic area? What you decide here matters quite a lot for any total estimate of plague deaths pre-pandemic.

For the time range, I picked 3000BC - 541AD. Starting the counter at 3000BC is fairly conservative - plague speciated quite a bit earlier - splitting off from the ancestor it shares with Yersinia pseudotuberculosis, a relatively mild pathogen, somewhere between 35,000-80,000 years ago! ³, but luckily, the number of people that lived prior to 3000BC isn't that large to begin with - the world population grew from about 2 million people 50,000 years ago to about 60 million people 3000BC.

For the geographic range, I took a broader view than just the regions where ancient plague has been discovered. I picked all the countries in Eurasia west of the China-India axis (excluding China and India, until solid aDNA evidence comes from those regions). I also included the countries in Africa that border the Mediterranean, as that coastline has long been connected to Europe. In addition, I added a group of countries in Central Africa, because an analysis of the plague strains that persist until today in those countries suggests that plague has been there for at least 3,000 years (now that current-day plague strains have been tentatively linked to the "Angola" strain that lies very deep into plague's phylogenetic tree) ⁴. You can look at an image of this range [here] (prepandemic-plague-range-estimate-large.png).

If you take the timeframe of 3000BC - 541AD, and the above geographic range, and run the numbers, you get a rough approximation of 537 million people that died of plague prior to the three plague pandemics.

To give you a feeling for the uncertainty in this estimate; the largest is demographic uncertainty: using the upper and lower bound estimates for population sizes from HYDE 3.2 can double the tally or reduce it to 1/4th of 537 million. The uncertainty of geographic range is also a large factor: the estimates of 537 million is halved if we limit ourselves to just the countries that reported aDNA samples, and triples if we include China and India. The impact of including a longer timeframe, say up until 10,000BC (the furthest back that HYDE 3.2 goes) only increases the tally by a fifth. Combined, these factors give a range of 48 million to 3.3 billion deaths, and still not represent all the uncertainty we have: for example, our 6% all-cause mortality has its own confidence interval as well.

The First Plague Pandemic🔗

Fast forward to the year 541 AD in Pelusium, Egypt. The outbreak recorded in the historic records in Pelusium is typically considered the start of the First Plague Pandemic, which lasted until 750 AD. The plague spread across Europe, and DNA of the plague bacterium has been recovered from dozens of sites, confirming that this was indeed a plague pandemic^5,6. The plague may have well spread into Africa and Central Asia as well - we just have very little information about what happened outside of Europe.

There is a very lively scientific discussion ongoing on how deadly this first plague pandemic actually was^7,8, and it is worth reading both sides to get a feeling for the challenges of tallying up the dead in historic times.

The upper range is at the 15-100 million people in those 250 years, when you limited the counting to just Europe. EXPAND

In between the First Two Pandemics🔗

If you somehow succeeded in tackling the challenges of enumerating the dead from prehistoric plague outbreaks and from the First Plague Pandemic, be mindful that you do not skip over the period between the end of the First Pandemic in 750 AD and the traditional start of the Second Pandemic in 1346 AD⁹.

It has been something of an entrenched idea that the Black Death was the start of the Second Plague Pandemic, which means that outbreaks between 750 AD and 1346 AD were not considered in the context of possibly being plague. That idea is changing now with a recent publication on plague in Baghdad, Iraq in 1258 AD¹⁰, and it wouldn't do to forget those places in an accurate tally of the total death toll of the plague.

But the period is in between the pandemics, so perhaps we should assume a lower all-cause mortality that during pandemic times. I have a very shaky estimate of 1.5% for the all-cause mortality during the second plague pandemic, so we should probably go for a lower number in between the pandemics. And perhaps we should scale back the geographic range as well - even though plague outbreaks might have continued to occur in the Middle East, I would be surprised if plague was as prevalent as during the First or Second Plague Pandemic in Europe, and everyone failed to notice that.

The Second Plague Pandemic🔗

The Second Plague Pandemic was fairly brutal. Besides wiping out half of Europe to start with (the usual estimate is 30-60%), the disease also kept recurring at lower city-wide mortality levels. Common pattern for urban areas are visible in Haarlem (Davis), which is still comparable to (the uncommonly large) London - as in every 40 years a 20% mortality crisis, and every 3-4 years a 5% crisis. That tallies up to a 1.5% all-case mortality.

That would be a full % lower than the 2.5% all-case mortality that was our rough estimate for pre-pandemic plague.

In between the Second and Third Pandemics🔗

When did the Second Plague Pandemic end? The outbreaks that are typically considered to represent the end of the Second Pandemic (the plague of Marseille in 1720-1722 or the plague in Moscow in 1770-1772), are only so from a rather narrow western-Europe perspective.

When you take older compendiums of plague, such as that of Georg Sticker ¹¹, you will find records of (presumably) plague present from Eastern Europe to India between 1723 to 1893. With the Third plague pandemic starting in Southwest China in 1788 or 1855, depending on who you ask, there is actually an overlap between the end of the Second and the start of the Third pandemic.

The Third Plague Pandemic🔗

The Third Pandemic can best be split up continent by continent, as different continents had very different death tolls ([see my guest post on lrhmatters.com])(https://lrhmatters.com/drivers-of-health/the-virtual-eradication-of-plague).

Making the roughest of estimates, we can say that by far the largest death-toll was in India and Southern China, for a total of about 21 million people.

After the Third Pandemic.🔗

There is not really a well-defined end of the Third Pandemic, but looking at various papers from different continents (Bramanti, Kuguler, Sun, Neerincxk, Jones), plague stopped being an epidemic disease around the 1950's, with case numbers returning globally to close to 0. Plague kept flaring up in outbreaks spilling over from local wildlife reservoirs after the '50s, but there is nothing that signals that plague was still spreading by human agency, like it did during the pandemics.

WHO used to have a dataset online of plague cases per year and per country, but no longer so. So I compiled the summary reports published by the WHO, to get a total (reported!) number of cases and deaths from 1954 until 2018. These reports contain some copy-paste errors and typos (the totals in the report seem to have been added up by hand, and sometimes a row is shifted one entry), but by browsing the WER archives and by doing some comparative work between WER reports, I removed most of these errors. You can download the excel file here.

The global total for the period of 65 years from 1954 to 2018 sums up to 1,149,952 cases and 9874 deaths, or about 150 deaths per year.

How many people died of the Black Plague?🔗

From the incomplete calculations above, we can see that plague from 1850 onwards killed in the region of 21 million people. We also have a shaky estimate for the time period from 3,000 BC to 750 AC of somewhere in the region of 270 million people.

That leaves the period of 750 AC to 1850 AC. I will keep you waiting a little longer, while I update the numbers and the methodology until I have at least something of an estimate.

Footnotes🔗