How the Black Death Shaped Modern Public Health Emergency Preparedness: A Review of Expelling the Plague

One of the core functions of government is to keep those whose individual rights it was constituted to protect free from contagion from other humans (through both accidental non-deliberate transmission as well as deliberate transmission in acts of biological warfare or bioterrorism) . This function  manifested through infectious disease surveillance programs, quarantine and isolation laws, and various biodefense programs. These programs are largely managed through public health agencies that have existed for quite some time and their place of origin is not a all obvious as these organized activities really began several centuries ago in the time of the Black Death (1377) on the Dalmatian Coast in a now-defunct republic called Ragusa (Dubrovnik) -- now part of Croatia. 

The operations of this nascent public health office and its battle with the plague are the subject of the 2015 book Expelling the Plague: The Health Office and the Implementation of Quarantine in Dubrovnik, 1377– 1533 by Zlata Blažina Tomić and Vesna Blažina. In this scholarly book, the literal day-to-day operations of this agency are recounted in meticulous detail drawn from extensive records from the city-state that still exist. 

I think it was prescient of the Ragusans to realize, as the authors note, that "more threatening than the mortality itself was, and still is, the challenge of the epidemic disease to the ideological structures that sustain all societies. The sense of origin, identity, purpose, and future of a society are all badly shaken and seriously disrupted by epidemics." This recognition underlies the creation of the health office, its prominence, and the delegated powers it possessed. 

The authors emphasize how important scientific knowledge underlied the use of quarantine as it is preventive isolation and presupposes the ideas of contagion (before the articulation of the germ theory of disease, health carriers, and the limitations of physical examination. 

The book also details the sentences -- many of which were extremely severe -- for those who broke the laws. These sentences were matched to the severity of the consequences of the accused action (e.g. did it lead to the death of someone) and could range from fines to branding to execution. 

To me, the chief value of this academic work is the illustration of a pioneering proactive approach to infectious disease outbreak management that forms the basis of how many nations respond to these threats over 600 years later. While the penalties imposed are revolting to the modern reader (or should be), it is important to not drop historical context and fail to realize that the Ragusans were reacting to what would be, in modern terms, a global catastrophic biological risk. 

Plague, Magnet Cities, and the Ottoman Empire: A Review of Plague and Empire in the Early Modern Mediterranean World

One of the most fascinating and impactful infectious disease outbreaks in history is the Black Death. This globally catastrophic event swept over much of the inhabited world in the medieval period when humans entered a cycle of infection between rodents, fleas, and the Yersinia pestis bacterium. There have been many many books written about this topic, some of which I have read. The latest to pop up on my list is very different than many of the others I have read because it is a truly scholarly effort. Plague and Empire in the Early Modern Mediterranean World: The Ottoman Experience 1347-1600 by Rutgers history professor Nukhet Varlik is an exhaustively researched, yet easily readable, treatment of not only how plague impacted the Ottoman Empire but, interestingly, how the Ottoman Empire impacted plague.

The book is divided into three parts and it covers three distinct phases of the plague expertly interweaving the narrative of disease with the workings of the bureaucratic regime that increasingly began to characterize the Ottoman Empire. Varlik shows how the trajectories of a bacterium and an Empire became intertwined. Starting with the nascent empire, Varlik shows how the increasing "constellation of connections" this empire developed -- east/west, north/south -- fostered new vehicles for plague to entire the Empire and to spread throughout and outside of it.

As she writes, "Consolidating the intersecting trade networks connecting the Balkans, Caucasus and Central Asia, Asia Minor, the Arabian Peninsula, Persia, North Africa, and the eastern Mediterranean provided a new set of connections over which plague could spread extensively both within the Ottoman domains and beyond."

A few interesting aspects of the book include:

• An explanation of the "capital effect" of migration to a major city such as Istanbul, which she labels a "magnet"
• The fact that not having enough fleas or lice on one's body was considered abnormal during this time period (having none could mistake one for being a leper)
• The first plague outbreaks spread from Europe to the Empire
• Once Cairo was incorporated into the empire both a east-west and north-south axis of plague spread became entrenched and plague became more endemic in the Empire
• Murders could go unnoticed if thought to be from plague

The book's value also lies in how it captures the medicalization of plague and how it moved from being the "decree of heaven" to something that, though the cause was not known, was natural and how reliance shifted from religious to secular authorities. The rise of public health measures in the Empire also developed in response to the plague.

Today plague is largely a forgotten disease in most of the Western World -- indeed people have forgotten that the Western US is home to plague and each time an animal or human case is reported, the media takes notice.

Plague is not the threat it was in the 1300s because humans tamed it through the use of their minds.By discovering its flea vector, describing its various forms (bubonic, septicemic, and pneumonic), and developing effective antibiotic therapies plague was defanged and naturally occurring plague can really never threaten the human race (a bioterrorist attack is whole different matter). However, it is important to be able to recognize what an infectious disease could do under the right circumstances and how networks of trade and commerce facilitate the passage of good and microbes and for this, Plague and Modern Empire is an excellent resource. 

Plague and Cholera: A Portrait of A Genius

When people speak of the influence of Louis Pasteur they often delimit it to the actual breakthroughs which he directly presided over. Though enormous in its scope, limiting Pasteur's achievements to just these does not do him justice. Not only did Pasteur discover a great many things (germ theory of disease, rabies vaccination, anthrax vaccination, pasteurization, the falsehood of spontaneous generation) his discoveries provided a green light for others to follow in his path--indeed he overtly cultivated a band of Pasteurians who pushed the field further and to whom we all owe a debt of gratitude.

Of the Pasteurians, one in particular deserves special mention and consideration: Alexandre Yersin, the subject of a recent fictionalized biography entitled Plague and Cholera written by Patrick Deville. 

Fictionalized biographies are tricky as the author must balance presenting a plot while staying somewhat bounded by actual events in the subject's life and I believe Deville accomplishes this expertly.

Yersin is chiefly remembered today for his discovery of the plague bacillus, which today bears his name. This story of Yersin's discovery, in spite of the odds tilted in favor of Kitasato a rival from the Koch Institute, was one I was familiar with but I had little knowledge of Yersin's life outside this episode and upon learning of it my admiration for his genius has grown.

Yersin was a true polymath who excelled and made advancements not just in microbiology but in botany, agriculture, geography, and many other fields. He basically had to be dragged from his hobbies in order to solve infectious disease problems, which he did in a manner that makes it look easy before returning to his hobbies. He is portrayed as a solitary, independent-minded man--a theme of many of the lives of innovators and geniuses--whose fascination with the world was never-ending. 

My favorite quote from the book is a great description of the Pasteurians and those who study and treat infectious diseases to this day:

"They are daredevils, too, adventurers, because in that day and age there is as much danger in getting close to infectious diseases as in taking off in an aircraft made of wood. A crowd of loners."

Never awarded a Nobel Prize, Yersin's life serves as an exemplar of a genius at work at the relentless pursuit of understanding. I highly recommend Plague and Cholera. 

The NYC Subway: Plague & Anthrax, but not Urine, Free

I often tell people that bacteria are everywhere, because they are. They lurk in almost every niche of the planet, including all the niches in and on our bodies. Some are found in more abundance in certain environments such as fresh water, salt water, on reptiles, in the soil, etc. 

So, when a study reported all the myriad microbes found in the NYC subway, I wasn't surprised as it as a perfect Petri dish for many different microbes because many people traverse it, it is littered with discarded food and often has puddles of liquid (which could be rain water on a good day, urine or some other substance on a bad day). Plus, rodents abound. 

The controversial part of the study, which detailed many different microbes being present, was the researchers detection of the bacteria that cause plague and anthrax in the subway. Such a finding immediately grabbed headlines. I also didn't find this to be too surprising because it is well known that both Bacillus anthracis and Yersinia pestis are widely distributed in the enviroment--though Y.pestis tends to stay west of the "plague line".  

The study was back in the headlines earlier this week when the research time clarified their findings, which now exclude the detection of the plague and anthrax bacilli in the subway. 

I would caution people--and rats--to not breath too deep a sigh of relief in the subway as, though not at risk for plague or anthrax, the smell of urine might do you in. 

A Plague of Misinformation on NCIS: New Orleans

There's been a lot of criticism of the media during infectious disease outbreaks (current and past) about over-sensationalistic rhetoric that foments fear. However, a recent episode of the television program NCIS: New Orleans really breaks new ground in spreading misinformation. 

In the show's latest episode, a navy shipman is found dead of plague and sparks a major investigation. During the course of the show, a litany of misinformation is presented. Some of the inaccuracies:

• Plague in a dead body doesn't isn't particularly contagious to people who haven't even touched the body
• Plague is not unknown to the United States. In fact, cases are diagnosed every year
• There is no vaccine available for plague
• It only requires droplet/contact precautions; not space suits

When Hollywood portrays infectious disease outbreaks with brazen errors (widely known to be false), it is understandable that the general public has myriad questions during real outbreaks.

When there are plenty of actual insoluble infectious disease problems to focus on why does Hollywood need to fabricate erroneous scenarios?