NO MONUMENT STANDS IN San Francisco to mark the city’s plague ordeal and the public health warriors who fought against it. The epidemic, once extinguished, was all but forgotten.
Joseph Kinyoun, the bacteriologist and quarantine officer who diagnosed San Francisco’s plague, was chased out of town as an archenemy of the people. As a scientist, he was undone by mercenary politicians, who bartered the city’s health for trade. He was a victim of official denial and protectionism. But his character, in turn, fed the city’s animus. He was proud, isolated, dismissive of the very plague patients who most needed his help. Clashing with the Chinese and pouring fuel on the city’s anger, he was, in his own view, at war with everyone. Kinyoun’s quarantines and travel restrictions against Asians, while supported by his superiors, were crude and discriminatory tools. Moreover, we now know that, even if the courts had not overturned them, such measures would not have stopped bubonic plague. Wounded and uncomprehending, Kinyoun quit San Francisco, and shortly afterward, the public health service. His career on the national stage was over, and its premature end was a reminder that science without compassion is a dry and punitive discipline.
After leaving San Francisco in 1901 at age forty, Kinyoun returned to the East and worked as director of a company making vaccines and antitoxins, as a professor of bacteriology and pathology at the George Washington University School of Medicine, and as the city bacteriologist of Washington, D.C. During World War I, he served the U.S. Army as an expert epidemiologist. Not long after the armistice, however, Kinyoun developed an aggressive lymphoma of his neck. In 1919 at age fifty-eight, he died.1
History has been kinder to Kinyoun than his contemporaries were. For his founding role in the National Hygienic Laboratory, forerunner of the National Institutes of Health (NIH), he is posthumously recognized as the first director of the NIH. It was the work of his youth—applying the powerful tools of bacteriology to the diagnosis of infectious disease—that survives him, untainted by the political and racial poison that infected so many people in 1900.
Rupert Blue, who leapt from San Francisco to the surgeon generalcy, fared far better. To some degree, history favored his endeavors. Just when he took command of the situation in San Francisco, medical science finally grasped the facts about the transmission of bubonic plague. And it was Blue who put those findings into practice in San Francisco. Once rat fleas were identified as the primary culprits, Blue could spare people the ruinous consequences of quarantine, and focus on killing rats.
The personae of Kinyoun and Blue are a study in the making or unmaking of an effective public health leader. Kinyoun had the science and the intellect, but he lacked human relations skills as well as a vision of what public health could bring to suffering populations. Whatever his private feelings about race, Blue did not antagonize San Francisco’s long-suffering minority community. And despite his professed phobia for public speaking, Blue possessed the polish and charm to engage the public, to persuade, to educate, to galvanize change in the field of public health. More than that, he had a populist vision of harnessing public health, not just to lock out epidemics at the border, but to alleviate suffering and improve the life of the people.2
However honeyed his style, his leadership wouldn’t have worked had not Blue, the pugilist, known when it was time to take off his gloves. As historian Guenter Risse has said, “Friendly persuasion was reinforced with intimidation.” It was only when he threatened the feckless city with loss of the Great White Fleet that Blue “fully engaged the powers of his office” as commander of the plague campaign.3
As the sanitarian who liberated San Francisco from bubonic plague in 1908, Blue gained a reputation for the kind of vigorous epidemiology the country needed. He served as the country’s surgeon general from 1912 to 1920, a period when world conflict and vast migrations of soldiers once more carried diseases around the globe. During World War I, Blue fought the twin epidemics of influenza and venereal disease. Although the AMA in 1915 named him the doctor who did the most good for humanity, his legacy was damaged by global events over which he had little control. Saddled with that nightmare of all reformers—an underfunded congressional mandate—he struggled to convert hospitals nationwide into veterans medical centers with too little staff and money to do the job. Had he been a tougher politician, he might have managed it, but it’s likely no administrator could have met all the demands of postwar civilian and military health. Under such pressure, Blue’s dream of a third term devoted to national health insurance died. His goals of mandating universal milk pasteurization and a network of child health clinics were dashed as well. By 1920, Blue was out, his public health vision outdated and undone by a welter of political forces. He remained in the public health service as an assistant surgeon general, serving in domestic plague outbreaks and in international health conferences.
Despite years spent purging plague on the San Francisco Bay, Blue had failed in all attempts to push his victory beyond the county line. For years, he had warned Washington about the danger of plague spreading to squirrels in the countryside. He had implored Washington for men, tents, rifles, and traps to rout the rural infestation. But his requests were deferred or denied. By the time he got approval to send a force into the East Bay, it was too late. Plague had spread to wildlife over thousands of square miles of California hills and grasslands.
It didn’t stop at the East Bay hills, but spread eastward, over the Sierra Nevada mountains and into the Rocky Mountains. In each zone, the fleas found a new host animal, jumping from rats to ground squirrels, then to the golden-mantled squirrels of the Sierras, then to chipmunks and prairie dogs who inhabit villages of burrows throughout the Southwest. Plague’s natural reservoir has always been rodents, and it found a home in the wildlife of the American Southwest, where it still smolders a century later.
Today, pockets of wild plague are scattered over vast territories around the globe. Colby Rucker’s 1909 plague map, with its P-shaped stain over California, has grown into a thick band of plague that covers the western third of the United States from the Rockies to the Pacific. Around the world, plague is scattered widely across Eurasia, Africa, and the Americas. Over the last five decades, the World Health Organization has monitored plague reports from thirty-eight countries, including notification of over eighty thousand cases and almost seven thousand deaths. Seven countries experience plague cases almost every year: Brazil, Congo, Madagascar, Myanmar, Peru, Vietnam, and the United States.4
Modern plague scientists from the U.S. Centers for Disease Control and Prevention (CDC)—men and women who are heirs to Rupert Blue—run a surveillance station in Fort Collins, Colorado. While the disease is considered too deeply embedded in the wild to be eradicated, the CDC and state health departments monitor wildlife, control fleas, and report to the WHO. When plague levels rise dangerously high, they post warnings to protect hikers and campers and sometimes even close state parks until the danger subsides. Warning signs showing a squirrel inside a red circle with a diagonal slash are a common sight in parklands throughout the West.
Such vigilance doesn’t prevent about a dozen people in the United States from contracting bubonic plague every year. Hunters, trappers, campers, and country dwellers are at the greatest risk. The expansion of residential development into the high deserts and foothills of New Mexico, Arizona, Colorado, and Utah brings people closer to plague country. Cats and dogs exploring infected burrows can pick up fleas and become a link between infected wild rodents and people. From 1977 though 1998, twenty-three people contracted plague from sick cats. Five of them died, casualties of misdiagnosis or delayed treatment.5
For patients today, modern antibiotics render the plague far less deadly. A course of intravenous streptomycin or other antibiotic offers most people a ready cure. But its efficacy depends on a swift diagnosis and timely treatment. Doctors in the Southwest are acutely aware of what a sudden attack of swollen glands and fever can portend. Such knowledge has saved scores of people in recent years. One of them was Debra Welsh.
Right before New Year’s Day 2000, the forty-three-year-old woman, who lives in the country north of Albuquerque, New Mexico, noticed that her house was invaded by little drunken, wobbly mice. She caught the mice in her hand, holding them with a paper towel. She flushed them down the toilet and washed her hands with antibacterial soap. Later, odd symptoms emerged.
A swollen lymph node appeared. The chills began. Intense aches and back pain hinted of something more grave. Following admission to St. Joseph’s Hospital, she was diagnosed with bubonic plague. A course of twenty-first-century antibiotics saved her from a medieval fate.6
A century after its discovery, untreated plague remains one of the most deadly diseases known to humankind. Without treatment, the mortality of bubonic plague ranges from 50 to 70 percent. When untreated plague spreads to the lungs or bloodstream—as pneumonic or septicemic plague—the mortality rises to nearly 100 percent.
Since plague is so lethal, San Francisco was lucky to have only 280 reported cases. Some people might wonder whether this represented a real epidemic. Kenneth Gage of the Centers for Disease Control and Prevention says the answer is yes. An epidemic is defined as any increase over the normal, baseline incidence of a disease. Before 1900, plague had no normal incidence in the Unites States. The San Francisco plague cases represented the first known outbreak in the continental United States. From that outbreak, plague established a foothold across the western states. Today, despite preventive vaccines and antibiotics, plague occurs in roughly a dozen people a year. Even forty cases of bubonic plague in any twenty-first-century American city would be considered an epidemic and an emergency. So 280 confirmed cases and 172 deaths certainly qualifies.
“San Francisco was clearly an epidemic,” confirms Gage—no relative of the old California governor. “We would go crazy if we had that number of cases right now.”7
Gage is a plague expert with the CDC in Fort Collins, Colorado. As an authority on the odd parasitic relationship between rat and flea, Gage says the San Francisco outbreak could have killed many more if it weren’t for that odd quirk of anatomy in the flea’s gizzard. He is among those who believe that the 1894 plague pandemic killed millions in Asia partly because its carrier was the Oriental rat flea, with its spiny foregut. Dr. Gage believes San Francisco was spared a similar fate because most of the local fleas lacked the anatomy of a killer.
All the other ingredients for an epidemic of devastating mortality were in place: the same bubonic plague germ, a massive population of rats, and a populace numbed by racism, ignorance, greed, and protectionism. A mote inside a speck of an insect saved the Barbary Coast from the fate of Florence or London.
People might wonder if San Francisco had a milder strain of plague bacteria. But Gage says this is unlikely. The strain covering the western United States today, which emanated from 1900 San Francisco, is the same one that savaged Asia and spread around the globe during the pandemic of 1894. Even more powerful evidence of this shared strain is the fact that those who did contract plague in San Francisco died with breathtaking speed. The mortality of the first plague outbreak in Chinatown was 93 percent. In the second citywide outbreak in 1907, the mortality rate fell to under 50 percent, thanks to faster diagnosis, hospitalization, and treatment with Yersin’s antiserum. Such treatment, though primitive by today’s standards and lacking in curative antibiotic drugs, would have included fluids, fever medication, and nursing care. It may have helped save patients’ lives, or at least eased their deaths.
The decade of the Barbary plague, 1900–1909, was a transitional moment in history between Victorian and modern San Francisco. Many of its landmarks have been destroyed by earthquake or razed by subsequent development. The corner of Dupont (today’s Grant Avenue) and Jackson Street, the site of the Globe Hotel, where Wong Chut King died, is today occupied by a glass-fronted retail bank. Where the Japanese brothel once stood, small trading companies and clothing stores rub elbows with souvenir and herbalist shops. The Merchant Street laboratory was leveled by the 1906 earthquake, but the alley remains as a passage between Chinatown and the skyline-piercing tower of the Transamerica Pyramid. Portsmouth Square, once dotted with quarantine tents, is a park once more where children play and aged Chinese do their morning tai chi exercises.
The Victorian house at 401 Fillmore Street that was home to the plague lab and rattery is now gone, replaced by a bland stucco apartment. Lobos Square, where the plague attacked eighteen refugees in their earthquake shelters, is now a park called Moscone Playground, just a block from the marina and yacht harbor. But the century-old Merchants’ Exchange on California Street is intact; strollers can still walk inside the building where Rupert Blue rallied the citizens and transformed their apathy into activism.
Angel Island is now a state park. Nothing remains of Kinyoun’s 1900 quarantine station at Hospital Cove, now Ayala Cove. Immigrants’ detention barracks, opened in 1910, are now a museum where poems carved in Chinese characters on the walls give mute testimony to the pain of exclusion. The smell of disinfectant baths is today replaced by the scent of barbecue. Boats arrive to disgorge not waves of immigrants, but waves of picnickers who come for a day in the sun.
San Francisco’s epidemic response, though slow to arouse, served the city well almost a century later in 1981, when acquired immunodeficiency syndrome struck its homosexual community. In the early days of the AIDS epidemic, when denial or discrimination clouded the country’s vision, San Francisco was a model of swift and compassionate care. Today, as other epidemics strike, stricken countries must sometimes learn all over again that the politics of denial, commercial protectionism, and discrimination too often trump science and sound medical judgment. Mad cow disease, or bovine spongiform encephalopathy, a brain-wasting disorder, ravaged British cattle herds in the 1980s and 1990s. The human form of the disease, called variant Creutzfeld-Jakob disease, has so far lethally infected 125 people in the process. Might this tragedy have been avoided if government and industry has acted sooner? Denial, protectionism, and the search for scapegoats arise when epidemics strike. The politics of 1900 San Francisco, far from being an anomaly, simply forshadowed the dynamics of epidemics to come.
By now, a sophisticated public knows that germs don’t respect national boundaries. Yet ironically, when plague struck India in 1994, Americans eyed their international airports with terror. What if a person, sick with the highly contagious pneumonic form, had boarded a plane in Bombay or Delhi and landed in New York? Those who were the most afraid didn’t know plague was already deeply imbedded in the landscape of the American West. Borders that were porous a century ago are even less substantial today in an age of jet travel. Disease fighters at CDC have even less time to prepare than they had in the era of travel by steamship.
The eradication or control of many infectious diseases from smallpox to polio has led us, we’re often told, to a false sense of security. In September 2001, the arrival of anthrax spores in letters awakened the world to the reality that old diseases may return as tools of terror.
Erosion of the public health system left the country vulnerable, just as these diseases come out of retirement. Whether they are in the hands of domestic murderers, stateless terror cells, or large state-funded weapons programs, this threat requires the same preparedness for massive outbreaks as the country faced in centuries past.
In a haunting counterpoint to Blue’s struggle to subdue plague, several countries of the world have studied the germ as a candidate for biological weapons. As early as the fourteenth century, Tatar soldiers hurled plague-infected corpses over town walls in the present-day Crimea. In World War II, the Japanese refined germ warfare a bit, by raising infected rats and fleas in grain-filled bathtubs, and sifting the lethal insects over unsuspecting people in China. After decades of official denial, the Tokyo District Court in August 2002 acknowledged that the attacks took place, in a reversal reported by the world’s press.
During the Cold War, the United States explored making plague weapons, but was thwarted when the germ cultures lost virulence over time in the test tube.8 The project was abandoned, but not without exacting a price. In 1959, a young chemist who was analyzing plague at the U.S. Army’s laboratory in Fort Detrick, Maryland, was swept by chills and fever, vomiting, and a bloody cough. Despite having taken the vaccine and booster shots, he was saved only by massive doses of streptomycin. Narrowly surviving pneumonic plague, he suffered liver damage from his ordeal. Three years later, a veteran microbiologist at Fort Detrick’s British counterpart in Porton Down, England, was less fortunate. While studying Y. pestis for defensive purposes, he contracted pneumonic plague and perished in a Salisbury hospital. After an investigation, his death was ruled a “medical misadventure.”9
Both the United States and England abandoned their biological weapons research decades ago, and signed the Biological Weapons Convention, banning germ warfare in 1975. However, the former Soviet Union continued its massive, covert bioweapons program until 1992. While debriefing defectors, Westerners learned for the first time of Soviet ambitions to create the deadliest of plague weapons—along with anthrax, smallpox, and other scourges. Unlike Japan’s primitive rain of fleas on Manchuria during World War II, the Russians improved the hardiness of the plague bacterium, which it code-named “L1.” At its weapons plant in the city of Kirov, it maintained a quota of twenty tons of pure plague in its arsenal.10
Defectors such as Kenneth Alibek worry that the specter of plague as a doomsday weapon has secretly survived the public dismantling of the Soviet bioweapons industry. However, the threat has also given new impetus to ongoing scientific initiatives to analyze and understand the genetic blueprint of Y. pestis. In one breakthrough, announced just three weeks after the terror attacks of September 11 on the World Trade Center and the Pentagon, British researchers deciphered the complete genome of plague. The British Ministry of Defense is developing a new vaccine to prevent plague outright. American researchers are devising fast DNA fingerprinting systems to speed detection of the organism—whether it occurs naturally or arises at the hands of terrorists. French scientists are bringing into focus the special “virulence genes,” which give plague a lethal edge over its ancestor Yersinia pseudotuberculosis.11
For plague doctors, the days before Paul-Louis Simond’s flea discovery were like the days before Walter Reed discovered the role of mosquitoes in yellow fever.
“We were fighting in the dark,” Blue said.12
Through his tenure as surgeon general and afterward, Rupert Blue revisited his years as a plague fighter. And sometimes they revisited him. Ragtag men would appear at his Washington office without an appointment, startling his secretary.
“Just dropped by to visit with Dr. Blue for a minute,” announced the veterans of Blue’s old rat brigades.13
Ushered into Blue’s office, they saw a figure thicker about the waist, his boxer’s chest now avalanched into a paunch that strained his vest and watch fob. Gray at the temples, he’d kept his trademark mustache. Blue welcomed the frayed visitors to reminisce a moment about the days of the quarter bounty and the rainbow rats.
Blue never lost his appetite for fieldwork—even after his tenure as surgeon general was over. He happily got back into harness to travel west and confront his old nemesis, the rat, when a plague outbreak claimed thirty victims in Los Angeles in 1924. He urged that the country maintain a standing force of public health officers ready to take the field to fight outbreaks at a moment’s notice, as he had done throughout his career.
He often received letters from a public curious about the modern toll of an ancient scourge. One of them was from Alda Will, a woman in Coronado, California, who wrote the surgeon general seeking advice for a friend who had survived bubonic plague. She asked what lingering aftereffects her friend might suffer.
Dear Madam, Blue cautioned, the scourge of bubonic plague leaves “severe traces” on the human heart, and it may never be the same.14