Rage Against The Machine: A Brief Review of Randall's Black Death at the Golden Gate

Several weeks ago news headlines carried stories of a spattering of plague cases in China. To those who follow infectious disease, it was not surprising as parts of Asia is considered the home of plague and cases occur there with regularity. But despite these facts, media headlines invoked the Black Death. The Black Death, which occurred over 500 years ago, was a calamitous outbreak of plague that likely killed one-third of Europe’s population.

The news stories about these latest cases almost universally left out the context of the Black Death — no supportive care, no antibiotics, and malnutrition. They also did not mention that though person-to-person spread of plague involving the lungs — pneumonic — is possible, it is rare (and the cases reported were bubonic which should prompt little in the way of special measures).

While this was all happening, i was in the middle of a new book on the topic of plague entitled Black Death at The Golden Gate: The Race to Save America from the Bubonic Plague. This book, published in 2019, by David Randall tells the story of the turn-of-the-century outbreak of bubonic plague in San Francisco. This subject has been told before in books but Randall’s approach, to me, appeared fresh and full of details that I hadn’t quite recalled from prior reading on the subject.

In brief outline, the story of plague in San Francisco is one that is familiar to anyone who knows the history of infectious disease: a cycle of denial, overreaction, and bureaucratic interference. The backdrop of the events that occurred in San Francisco occurred in the midst of a power struggle between the US Surgeon General Walter Wyman and rising public health luminary Joseph Kinyoun who was exiled to the Angel Island quarantine station. At the time, plague had just raged in Hawaii leading to the literal burning of Honolulu’s Chinatown — an ominous development that Kinyoun did not want to occur in San Francisco

Plague first appeared in San Francisco as a single case in Chinatown prompting a draconian quarantine of the entire region and then, when tests were not fully completed, a reversal and then another quarantine. Randall also details the baffling stories of how plague deaths were hidden from authorities (which including propping dead bodies up to make them look alive). The book details the bureaucratic machinations that Kinyoun faced — including interference from President McKinley and the California governor (Gage) — and ultimately how he was replaced.

In the end, plague established itself in the US after public health measures failed to contain it and the book illustrates how failing to heed the warnings of public health authorities can prove disastrous. I think these themes are timeless and have been repeated countless times in outbreaks small and large from HIV, to hepatitis A, to SARS, to Ebola. I was struck by the lone brilliance of those like Kinyoun who were, instead of being rewarded, were punished for their foresight.

Randall also weaves in a great deal of the history of California, San Francisco, and the Chinese Six Companies into the narrative. He also highlights some of the anti-Chinese immigrant sentiment that permeated area even prior to the outbreak including mayoral candidates campaigning to keep California “white” and threats of violence against those that employed Chinese immigrants.

I highly recommend this book as a great introduction to the history of plague in the modern era but even more so as a great case study of how public health and infectious disease authorities face not only the microbe but often a hostile public and government leadership that must also be navigated with equal precaution.

Giving the Plague no Quarter in Madagascar

Plague, for very good reasons, is something that will always capture headlines and panic individuals. It is an infectious disease that entirely disrupted civilization on multiple occasions and has become the stuff of legends involving everyone from Roman emperors to Nostradamus. Indeed for most of human history plague, caused by a bacteria that spreads from rodents via the bite of flea, was an existential threat, until it was tamed by scientific discoveries that discovered its origin and its susceptibility to antibiotic therapy. In many parts of the world, this taming of plague has made it a non-issue but a new outbreak on the African island nation of Madagascar has some worrying characteristics that merit swift action to extinguish what could become a larger problem. 

In Madagascar, close to 700 individuals have been infected with 57 succumbing to the infection. What makes this outbreak particularly notable, despite occurring in a country that has hundreds of annual plague cases, is that many of the cases are of the pneumonic form. This form of plague, which involves infection of the lungs, is the form that can be transmitted between humans through coughs and sneezes in little droplets that travel about 3 feet. Also, cases are occurring in urban areas giving the bacteria more opportunity to find new hosts. 

These factors have prompted public health agencies to take prompt actions including the creation of a treatment center and the delivery of antibiotics. So far, the risk of international spread is low -- despite an importation to the Seychelles. However, in the wake of Ebola it is crucial, even in low international risk situations and with effective antibiotic therapies, to not allow infectious diseases to any breathing room 

The Dog Gave Me Plague

The recent detailing of the 4-person cluster of plague cases that occurred in Colorado in 2014 is a fascinating look at how plague, in the modern age, can still cause substantial morbidity. 

People forget that plague is endemic in parts of the US that are west of the "plague line" and we have a handful of cases each year in the US. What was special about this cluster was the involvement of a dog and possible human-to-human transmission in one instance. Additionally, half of the cases of pneumonic plague were mild and didn't require hospitalization, a fact that calls into question the common conception of plague as a universally severe illness.

The index mammal in this outbreak was a dog who was euthanized for an illness that caused bloody-tinged cough. This was subsequently diagnosed as plague and the property on which he lived had inactive prairie dog burrows and rabbits--known means for how the dog may have acquired its fatal affliction.

Didn't realize there was a movie with this title, unfortunately its anti-vivisection.

What happened next illustrates the concept of One Health, an approach to medicine and public health in which animal and human health issues are integrated, perfectly: 3-4 contacts of the dog became ill with plague. Of the 4 human cases, 3 had very close contact with the ailing dog and the remaining patient had some contact with the dog but also close contact with the dog's owner, raising the prospect that human-to-human transmission occurred--a phenomenon that hasn't occurred in the US for 70 years.

So, it's time to add spreading plague to the long litany of things, including their favorite pastime of eating homework, to blame on dogs 

Would Gerbils Obey the Pied Piper?

Rats are considered an unavoidable bane of urban life and have been generally associated with filth, disease, and pestilence. One of the most ominous events--The Black Death and the following European plague outbreaks--they have been linked to may not actually have involved them (they would blame it on the fleas anyway).

A new study suggests another rodent might have been to blame: the gerbil (actually the great gerbil from Asia). In this study, Schmid and colleagues looked at climatological data contained in tree rings in Europe and Asia (the traditional home of plague) to determine if such conditions were conducive to rat populations. The study attempts to unravel a few paradoxes regarding plague in Europe: what was the rodent reservoir that allowed plague to persist there (which disappeared in the late 19th century when plague outbreaks tapered off) and was plague something that seeded Europe at the time of The Black Death and persisted in rodent populations there? 

What the evidence presented in this paper suggests is that tree ring data in Europe from the time of known plague outbreaks do not support a climate suitable for rat populations to thrive. However, tree ring data from Asia do show a correlation with a climate conducive to gerbil population booms followed by  busts, forcing resident fleas to look for alternate hosts (i.e. humans and other animals, including rats). This finding is at odds with the traditional view that attributes the presence of plague in an infected European rat reservoir.

The authors speculate that repeated introductions of plague to Europe from Asia occurred to produce each plague outbreak--a finding that may absolve the rat of its role in perpetuating Europe's plague outbreaks. 

This study shouldn't dissuade people from having gerbils as pets as it is not applicable to captive gerbils. Similarly, it shouldn't encourage people to have rats as pets (don't forget about rat bite fever). 

What the study does do, at least for me, is provide another great concretization of how infectious diseases affect and are effected by absolutely everything: animal population, international trade, seasons, and, in the case of the Black Death, perhaps the structure of Western society. 

The "Laptop of Doom" & the Threat of Bioterrorism

Commenting on the ongoing Ebola outbreak, I often note that all the novel medications and vaccines being put in trials are the result of a recognition, post-anthrax, that Ebola could be a potential bioweapon. Almost 13 years have passed since Amerithrax and many have forgotten about the sense of alarm and calamity that gripped the nation in October of 2001. 

The specter of bioterrorism is in the headlines again with the revelation that a laptop found in Syria contained information about using plague as bioweapon. 

Unlike anthrax, plague--caused by the bacterium Yersinia pestis--can be transmissible from person-to-person.

Plague, like anthrax and Ebola, is also classified in the highest priority category (A) and has a long history of use as a bioweapon that stretches back to the times of The Black Death, when a Tartar commander catapulted plague-stricken corpses into the city of Caffa.

In the modern era, the bioweapons programs of the Soviets (and the US) also sought to weaponize plague. One fact that would delimit plague's effectiveness, however, is the fact that it is easily treatable with antibiotics and, upon exposure, prompt administration of antibiotics can abort infection. 

The lesson I draw from the discovery of this laptop is that, despite an absence from the headlines, the threat of bioterrorism is itself not absent.