The American Plague

by Molly Caldwell Crosby

  The city was divided into districts, and Gorgas sent his men into every home and dwelling in Havana for inspection. It was not an easy task. The locals would often hide containers when the “mosquito hunters” came through the neighborhood, but Gorgas would not be deterred. He soon had his officers keep accurate count of every container that could hold water—all had to be accounted for during an inspection. Barrels, jars and containers were given a slick, top layer of oil to suffocate mosquito eggs and wigglers. If people feared the oil or complained that it changed the taste of water, mosquito wire was strung across the top. Even mosquito traps were used—pans of fresh water were left out where the female mosquito could lay eggs. The water was then disinfected and the eggs killed before they could hatch.

  Gorgas also attacked the problem at local hospitals. Fever patients were strictly quarantined with mosquito netting over their beds and strips of paper sealing any cracks in the wooden-frame buildings. Pyrethrum, an insect powder, was burned inside the room, and a light was held in the corner to attract wayward mosquitoes and stun them.

  Finally, Gorgas made mosquito control a personal responsibility,sending out inspectors and fining citizens when mosquito larvae were found on their property or in their home. It is a practice still used today in Havana.

  Gorgas’s persistence proved highly effective. There was one yellow fever death in March 1901 and not a single one in the months of April, May or June. Malaria rates dropped dramatically as well. In their book Yellow Jack, John Pierce and Jim Writer wrote, “Yellow fever had been constantly present in Havana for 150 years and was nearly wiped out in less than 150 days.” Gorgas himself would write: “It seems to me that yellow fever will entirely disappear within this generation, and that the next generation will look on yellow fever as an extinct disease having only a historic interest. They will look on the yellow fever parasites as we do on the three-toed horse—as an animal that existed in the past, without any possibility of reappearing on the earth at any future time.”

  Gorgas would go on to apply the same techniques in the development of the Panama Canal. French engineer Ferdinand de Lesseps, who had earned fame building the Suez Canal, had attempted to build the Panama Canal in 1881. The seventy-four-year-old engineer was met with disastrous results and lost as many as one-third of the men to yellow fever and malaria. Eventually, the project was abandoned. In 1904, Gorgas was assigned as the medical officer to America’s Panama Canal project. President Theodore Roosevelt, a veteran of the Spanish-American War who could fully appreciate the devastating effects of yellow fever, fought to keep Gorgas in Panama in spite of political pressure to fire Gorgas and abandon his wild ideas about mosquitoes. Even Secretary of War William H. Taft pressured the president to remove Gorgas. Finally, a friend and doctor recommended to Roosevelt, “You must choose between the old method and the new; you must choose between failure with mosquitoes or success without them.”

  Gorgas again applied his aggressive techniques toward destroying the mosquito and all of its breeding grounds. Once again, Gorgas met with success. Though he continued to receive criticism from skeptics during the first few years of the canal project, he outlasted them all; and he was still the officer on duty when, in 1914, the first ships sailed through the Panama Canal. Gorgas wiped out the mosquitoes, and the cases of yellow fever and malaria dropped off the charts. By 1908, William C. Gorgas had been appointed president of the American Medical Association, and then he was named surgeon general of the U.S. Army, occupying that office during World War I and the 1918 influenza pandemic. But what Gorgas most looked forward to was returning his focus to the eradication of yellow fever. In 1920, Gorgas traveled to London en route to Africa where he would take part in a yellow fever study. While in London, Gorgas was to be honored by King George V. Before he could attend his own ceremony, however, Gorgas suffered a stroke and was admitted to a London hospital. The king visited Gorgas there, granting him knighthood. Sir William C. Gorgas died four weeks later.

  After the death of Juan Guitéras’s volunteers in Havana, most notably Clara Maass, the public protest against human volunteers reached an all-time high. That, with the fact that the army had eliminated most of the mosquito’s breeding places in Havana and surrounding areas, prompted the government to halt any further testing. Carroll returned to the United States. Though Sternberg recommended that Carroll be promoted to the rank of major, it was denied due to a moratorium on promotions. Instead, Carroll received a regular army commission as first lieutenant. It was not until 1907 that he would be promoted to the rank of major as a Special Act of Congress. In the same year, Carroll began suffering from heart problems. It was suspected that because of his age and the tremendous toll yellow fever took on his body, his heart had suffered irreparable damage. James Carroll died of valvular heart disease on September 16, 1907.

  When the Yellow Fever Board was dismantled, Agramonte decided to stay in Cuba where he began teaching at the University of Havana. His work with yellow fever, however, did not come to an end. He continued to champion Dr. Carlos Finlay and also defended the commission’s findings against future medical experiments involving yellow fever. Agramonte returned to the U.S. as a professor of tropical medicine at Louisiana State University in New Orleans, where he died in 1931. He was the only member of the Yellow Fever Board still alive to receive the gratitude of the U.S. government.

  In 1929, through an Act of Congress, Walter Reed, Jesse Lazear, Aristides Agramonte, James Carroll and the men who volunteered for the human experiments were awarded the Congressional Gold Medal, so that their services, in the interest of humanity, may never be forgotten. The names of those men are: James H. Andrus, John R. Bullard, A. W. Covington, William H. Dean, Wallace W. Forbes, Levi E. Folk, Paul Hamann, James L. Hanberry, Warren G. Jernegan, John R. Kissinger, John J. Moran, William Olsen, Charles G. Sontag, Clyde L. West, R. P. Cooke, Thomas M. England, James Hildebrand and Edward Weatherwalks. Nearly thirty years later, two more names were added to that list: Gustaf E. Lambert and Roger P. Ames, the nurse and doctor who treated the majority of yellow fever cases at Camp Lazear.

  Major William Borden, the friend who had performed Reed’s operation, began a campaign to build what would become known as “Borden’s Dream.” Borden wanted to combine the Army Medical Museum, Army Medical School and Surgeon General’s Library into a single medical center. And he wanted to name it for his friend Walter Reed.

  It would take years to get the appropriate funding to buy the forty-three acres of land at Georgia Avenue, NW, and Sixteenth Street, NW, in Washington, D.C. The Walter Reed General Hospital would admit its first patients in 1909. Other buildings were added over the years, including the Army Medical School, which would one day become the Walter Reed Army Institute of Research. And the Surgeon General’s Library, located downtown, would become the National Library of Medicine. The campus would change its name to the Walter Reed Army Medical Center in 1951 on the 100th anniversary of Reed’s birth.

  The redbrick hospital, complete with white columns and a fountain, originally held only 80 beds. When World War I broke out, that number jumped to 2,500. Today, the hospital admits close to 16,000 patients a year. Eventually, the center required more space and now has buildings in three different states, though the original hospital still stands in the District of Columbia. But not for long. The Walter Reed Army Medical Center is scheduled to close its doors for good by 2011, just over a century after it first opened. It will be combined with the Naval Medical Center in Bethesda, Maryland. Walter Reed’s name will live on, however; the new campus will be called the Walter Reed National Military Medical Center.

  PART FOUR

  United States, Present Day

  In recent years, popular attention has been drawn to . . .

  Ebola as the most frightening emerging infection of humankind.

  However, patients with yellow fever suffer as terrifying

  and untreatable a clinical disease, and yellow fever is

  responsible for 1000-fol
d more illness and death than Ebola.

  —Lancet Infectious Disease, 2001

  CHAPTER 24

  Epidemic

  It was March 10, 2002, when Tom McCullough checked into the emergency room in Corpus Christi, Texas. He had been suffering for four days from cramping, abdominal pain and severe headache. Then, he developed a fever approaching 103 degrees. The doctors in the ER thought it could be rickettsial disease, a term that covers a number of infections caused by vectors like ticks, fleas or contact with animals. Most rickettsia can be controlled with antibiotics, so the doctors prescribed just that and released him from the hospital. Two days later, he was back again, this time with intractable vomiting. McCullough had been a healthy, forty-seven-year-old man, but he now appeared weak and febrile. He repeatedly asked his wife, “What is happening to me?”

  A series of tests were performed, and he was treated for malaria though his blood test proved negative. McCullough developed anemia, his blood would not clot, and his kidneys and liver failed. He went into shock and developed seizures. He bled uncontrollably from the sites of his needle punctures. Tom McCullough died on March 15—leaving a wife and six children still wondering why.

  McCullough’s illness and death were reported to the Centers for Disease Control and Prevention (CDC) in Atlanta, which began their own series of tests looking for dengue, St. Louis encephalitis, spotted fever, leptospirosis, Machupo virus and yellow fever—all viruses known to exist in South America. McCullough, it had been reported to the CDC, had just returned from a week-long fishing trip for peacock bass on Brazil’s Rio Negro. The brochure for the trip read, We do not suggest any inoculations of any kind for this trip . . . But to make sure you are worry free, consult with your personal physician.

  It would seem that some vicious new virus had taken hold of Tom McCullough; instead it was an ancient one. One hundred years ago, doctors would have known immediately what killed him, but modern medicine takes longer. Today, there is a wealth of illnesses known to be caused by insect vectors of all types. There are antibiotics and vaccines to fight disease, and still, this fever seemed to defy contemporary medicine. At last, the autopsy showed antibodies to the yellow fever virus—McCullough’s internal struggle against a virus rapidly taking hold of his body. The CDC had reason to be concerned; McCullough was the third death from yellow fever since 1996, all three originating from trips to the Amazon region. Prior to that, there had not been a yellow fever death on American soil in nearly eighty years.

  Tom McCullough had told his wife that he could not remember being bitten by a mosquito during the trip. He slept in an air-conditioned boat and had worn DEET. Still, a mosquito had apparently found him, following the scent of carbon dioxide in the tropical air, perhaps hovering unnoticed around his ankles or legs, biting several times as he moved. But it only took one bite, a pinprick he never even noticed, and the lethal virus made its way into his bloodstream. McCullough’s body had never come in contact with this virus before. He had not had a yellow fever vaccine, and his blood came from stock that had not seen this virus in over a century.

  Had an Aedes aegypti mosquito in Texas bitten McCullough in the days before he checked into the hospital, hundreds more could have been infected. The virus would have been unleashed on a virgin population. In the mild Corpus Christi winter, virulent eggs could survive to the next summer when even more Aedes aegypti mosquitoes would carry the virus through another muggy Texas summer.

  At first, the virus would move quietly into the population. People would begin showing up at local emergency rooms with high fevers and flu-like symptoms. They would be released when they showed signs of improvement—yellow fever’s convalescent period. But as many as 50 percent of those people, and possibly many more than that, would enter the toxic phase of the disease and die.Their deaths might be blamed on any number of diseases—pneumonia, hepatitis, influenza, West Nile. Though mosquito bites, swollen and pink, might appear on the skin, no one would think to investigate further. After all, these patients live in the United States. They had not traveled to a tropical country; they had just spent a summer evening outdoors, or found a striped mosquito trapped in their car, or missed a few places of skin when they sprayed Off! on their children playing in the backyard.

  As the death toll began to mount, doctors in the local hospitals would begin reporting them to the state health department. Perhaps malaria or dengue had made its way from Central Americanorth. Health officials would be concerned. Resistant strains of malaria have been reported in recent years, and the CDC estimates that as many as 3,800 cases of dengue have appeared in the United States since the 1970s. Dengue is spread by the same mosquito that carries yellow fever. At last, the dead arriving from their homes or on gurneys in emergency rooms would begin to yellow, their skin taking on a bronze color, their eyes like sunflowers.

  The state health department would contact the CDC, which, under international law, must contact the World Health Organization within twenty-four hours to report any disease with jaundice and bleeding. Since its inception in the 1950s, the WHO’s International Health Regulations have required reporting of only three diseases: plague, cholera and yellow fever. All three diseases are subject to international quarantine.

  But in America, these diseases are so rare that doctors would doubtfully even recognize the symptoms in twenty-four hours. Americans traveling to the coastal areas of Texas for vacation would pick up the virus and fly home to cities like Houston, Dallas, Memphis and New Orleans, where entire colonies of Aedes aegypti live.

  In 2005, the CDC published a detailed response to an epidemic of yellow fever in Africa and the Americas. Field investigators, border officials and vector control would arrive. They would contact the Global Alliance for Vaccines and Immunization to report an epidemic and request that mass vaccines be delivered within the week. Those who already have the virus would have little chance for survival—they would be part of the nonimmune population, the kindling that the virus relies upon to spread. Vaccines would be given to hospital personnel and military first, but postexposure, it would do little good. In the time it would take the vaccine to prompt the production of antibodies, the virus would have run its course, leaving its host either immune or dead.

  A live vaccine, yellow fever can also have adverse effects. Infants, patients with depressed immune systems or anyone over the age of seventy-five cannot receive the vaccine. Though pregnant women are usually denied the attenuated vaccine for the safety of the fetus, the CDC would make an exception in the case of an epidemic. In the hospitals where yellow fever patients arrive, rooms would have to be screened and strictly quarantined. Lab technicians handling blood samples would have to follow strict procedure with gloves, masks and air purifiers.

  A general panic would settle into the city and surrounding ones as educational warnings on television and radio recommended that people cover their beds in netting. Informational pamphlets would instruct people to empty any outdoor water containers around their homes. In spite of the summer heat, people would wear pants, long sleeves and socks with shoes. Store shelves would be cleared of Off! and any other DEET products. Windows would be screened. Water and food stockpiling might occur as people prepared to board themselves up in their homes, keeping their children indoors. Public pools and parks might close. Chemicals would be pungent in the air as people sprayed insecticides on their lawns and in their homes. Vector control units would send out patrols of trucks and crop dusters to mass spray.

  The panic would worsen.

  Vaccines from the Global Alliance for Vaccines and Immunization would arrive, but not enough in the event of a full-scale outbreak. The GAVI only recently began stockpiling the yellow fever vaccine. Six million doses are reserved each year for an epidemic, and they could take a few million more from their reserves for routine vaccine usage. The CDC would assess which portions of the population are most in need of the vaccine, reserving several for the personnel, military and hospital staff. Even if all six million vaccines
arrived in a town like Corpus Christi, there would not be enough to inoculate cities the size of Houston and Dallas, much less other southern cities where the mosquitoes or infected people may have made their way.

  Cases would continue to appear well into December, spiking every time another warm front moves through the country. At long last the epidemic would subside, though it would live on in the news and on the covers of magazines for months. Major vaccine production programs would begin, grown in chicken eggs over the next six months. And, hopefully, there would be enough vaccines ready for the approach of warm weather the following spring when yellow fever season arrived once again. That is not always the case—especially in underdeveloped countries. After an outbreak of yellow fever that killed thousands in Nigeria during the 1990s, it took ten years to clear the population of the virus. In order to prevent an epidemic, at least 80 percent of a country must have immunity to yellow fever.

  According to the World Health Organization, even a single case of yellow fever must be treated as epidemic.

  CHAPTER 25

  A Return to Africa

  Dr. Adrian Stokes bound a monkey onto a cushioned board with gauze, keeping his head firmly strapped. For an hour, Stokes allowed Aedes aegypti mosquitoes to bite the monkey on his face, lips, ears. Then, he returned the monkey to its cage. It seemed a little cruel, but it was too dangerous for the doctors to hold the monkeys while loaded mosquitoes fed. Even with leather gloves on, the insects could bite through the stitching. Across the lab from the monkeys, in a cage with roughly six screens dividing it, mosquitoes hummed in their wire prison.