Sex, Drugs, and Public Health

         In early 1900, a merchant ship under sail neared the Golden Gate. It was proceeding from Hawai’i and had sailed from Asia before that. As it approached, it raised a yellow flag under order of Dr. Kinyoun, Chief Quarantine Officer of the U S Marine Hospital. An order that many businessmen and women of the city detested. The ship remained at quarantine until it was determined that no one on board was ill. It docked, according to some reports, very near the outflow of Chinatown’s sewer.

         On March 6, a 41 year-old man living at a hotel at the corner of Grant and Jackson streets in Chinatown, developed a fever. His condition rapidly progressed and several of his lymph nodes swelled, and became exceedingly painful. After his death, samples from his body were sent to Kinyoun’s lab on Angel Island.

         The first case of Bubonic Plague in the U.S. was diagnosed.

         The Third Pandemic of this ancient, terrifying disease had begun in Asia in 1855. Forty-five years later, it had sailed into San Francisco harbor.

         As the disease spread, two factions broke out. The first group recognized the disease and tried to launch a control program against it. This included the City Government, City Board of Health, many physicians and the U S Marine Hospital.

         The second faction, led by the State’s Governor Gage, fought against even acknowledging that Plague was present. Besides the Governor, this group included many S F business people, some physicians who were politically aligned with Gage, and many Chinese concerned about racist attacks.

         As the disease spread, battle lines were drawn. Kinyoun’s lab confirmed that it was Plague; Gage worried about the economy, denied the diagnosis, and defamed the scientist, Kinyoun. The U S Surgeon General empaneled a commission of experts, who confirmed the diagnosis; Gage denounced the findings, closed the U C Berkeley lab to the Federal scientists, and threatened funding to the University. The Surgeon General ordered Chinatown quarantined; Chinese brought a lawsuit which, shockingly, historically, they won (14^th amendment). Cases of the disease piled up; Gage accused Kinyoun of injecting cadavers with plague to falsify deaths, censored media on the topic, launched a P R campaign calling the outbreak a “fraud,” replaced the members of the State Board of Health with his supporters, and cut funding to the City Board of Health.

         Ultimately, the Case Fatality Rate was 98%.

         Also, ultimately, Gage lost the 1902 election to an ex-Oakland mayor and physician.  Immediate reforms changed the city significantly: a Citizen’s Health Committee was formed, laws were passed, a Plague Hospital built, understanding of the mode of transmission led to a rat control program, a new sewer system was built, stables were required to have cement floors, public sanitation improved, and screening of citizens was instituted.

         By the way, Plague is still with us, endemic in the rodent population of California (including the Sierra). Some believe that might have been prevented had Gage not delayed the early control.

         Lessons for us:

1. Although we can’t eradicate it or make it disappear, we CAN control an infectious disease epidemic. Been done before and we may still have time on this one. We just need to listen to the scientists.

2. The Health Officer has “Police Powers” for a reason – in order to fulfill his / her responsibility to protect Everyone, the Health Officer educates citizens, gives guidance, and depends on them to do the right thing. But there are always a few who will rebel, act stupidly, and jeopardize everyone else. Just as we need police to enforce the speed limit so some yahoo doesn’t do 110 MPH and kill others.

3. Bacteria (like Plague) and viruses don’t care about our religion, skin color, politics, good works or evil actions. They attack the Human Family. Therefore, each person’s actions either endanger or protect that Family. What others do affects you; what you do affects others, and not just in your household.

4. There will be changes to society after a shake-up like a major pandemic (or war). Just as Plague re-made San Francisco in 1902-1904, WW II caused the creation of England’s National Health Service for all. How will our society change post-Covid?

Will we prepare ourselves for the next gigantic Public Health threat (which is already looming)?

Will we re-structure our Health Care system so everyone has access? So 24 hour Urgent Care clinics are close to even the most remote populations? So that sophisticated Medical Technology is concentrated Regionally to maximize quality? So that Tele-Medicine can bring specialists to anyone?

Will we increase work and school from home?

         Will we re-assess how we process meat?

         Will we find a way to protect our unemployed from financial ruin?

         Will we reduce the excessive consumerism we thought was “normal?”

         Will we finally see the error in the axiom that government should be run like a business? (The false-ness of this one has been obvious to me for decades as I did both – private practice and public service. They are two institutions with completely different – indeed, conflicting – goals. One tries to make a profit. The other serves people’s needs).

         Will we re-discover the value of Art?

Big Science.

         We’re learning about this new disease as we go.  Medical clinicians and researchers from all over the world are sharing their information (a normal procedure in science). From autopsies, we’ve seen that the lung damage in Covid is different from that in Influenza. It includes damage to the blood vessels that carry oxygenated blood, not just damage to the lung tissue itself.  Damage is also seen sometimes in the kidneys, liver, heart and brain.  Blood clots form and can cause strokes. And you’ve probably heard of a rare blood vessel inflammation in some children and adolescents after a bout with Covid.

         All this information helps us know the disease process better and, therefore, treat it better. We can anticipate issues that may come up in a patient rather than being surprised. It will hopefully help us develop targeted therapy and vaccine.  It’s crucial to maintain open communication among all the countries of the world so that this information can grow.

Big Numbers.

         The U.S. has 4.5% of the world’s population. All things equal, and if we had mobilized the Pandemic Response resources we built up over the last decade, we should have had no more than 4.5% of Covid cases and deaths.  That would be 265,500 cases and 16,290 deaths.  However, the truth is, we have almost seven times that.

         No country has more Covid than the U.S. even though there are other countries with more population than us. We’re Number One.

         So we have a lot of work to do.

Remember that 98 % Case Fatality Rate of Plague in San Francisco? Here’s some good news:  when Plague returned to S F in 1907 (a second wave), they were better prepared and willing to address the issue with honesty.  As a result, the Case Fatality Rate was cut in half.

We know the right things to do to control Covid. We can’t change how contagious it is, but we can slow its spread, giving Medical Scientists time to learn the disease, work on prevention, and develop therapies. With Personal Distancing, face coverings when in public, and avoiding un-necessary exposure, we can bring this disease under our control.

And let’s also begin building the post-Covid society for us, our kids, and beyond.