Black Death at the Golden Gate
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Blue launched a statewide campaign to create what he called “squirrel-free zones” around California’s major cities, hoping to stave off another outbreak by reducing the number of wild squirrels—estimated at 100 million—living in the state. Landowners in the roughly mile-wide barriers were urged to dynamite all squirrel holes on their property, while health officials spread poison liberally, covering more than one thousand acres of Contra Costa County with tainted grain. Blue trained corps of trappers—many of them men who had seen military service in the Spanish American War and felt comfortable with a gun—in the habits and preferences of squirrels and urged them to kill as many as possible. “As the conditions stand today, it is evident that nothing short of a relentless campaign of rodent extermination can prevent the epizootic from spreading over the entire State,” Blue said in an address to the powerful Fruit Growers Convention in Stockton. “As long as there is one case in a country the whole world is afraid of it.”
Still the disease spread outward. Trappers in San Joaquin, Stanislaus and Merced counties found infected squirrels, as if it was traveling along vines emanating out of San Francisco and down the state. An infected squirrel was then found in the central California coastal county of San Luis Obispo, often considered the unofficial dividing line between the more populated northern and faster-growing southern halves of the state. Concerned that an urban outbreak would be next, Blue sent trappers into Los Angeles, Riverside, Orange and San Bernardino counties to assess the risk. The bodies of more than twelve thousand squirrels were shipped back to his laboratory. No evidence of plague was found, though Blue worried that it was only a matter of time.
Though his fears were rising, Blue had to concede more control of the squirrel campaign to his deputies. Now known as the savior of San Francisco, Blue was increasingly called away from his post whenever the Marine Hospital Service encountered a fearsome epidemic around the globe. He sailed down to the Chilean coastal town of Iquique when an outbreak of plague claimed more than a hundred victims, and spent weeks in Panama battling an outbreak of yellow fever. In each, he instituted sanitation methods similar to those that had worked in San Francisco. His reputation and personality served as a halo around the Service’s efforts, buffering local objections to the presence of federal health officers.
Blue was attempting to control a wave of yellow fever in Hawaii when, in November of 1911, he received word from Rucker that Wyman was dead. The failing health of the Surgeon General had long been an open secret within the Service, though no one dared to comment publicly on the future of a man who considered any remark on his status nothing less than betrayal. Overweight and diabetic, Wyman had increasingly cloistered himself in his office, rarely attending Service functions or meeting with officers in the field. Yet it was the sapping of his ambition that truly signaled that his life was nearing its end. Where he had once rushed to claim any additional federal mandate in hopes of making the Service into a more important agency, Wyman had in recent months dismissed new opportunities without regret, rejecting a proposal to create a Children’s Bureau within the Service that would provide care for new mothers and their infants by calling it merely sentimental.
Unwilling to the end to cede power, Wyman did not nominate a successor, upending the forty-year tradition of the office in which the outgoing Surgeon General chose his replacement. His death left the Service in a panic. Knowing that Blue would be too reticent to lobby for the job himself, Rucker sent Blue a telegram stating simply, “Wyman dead. Have entered you in race. Too late [to] back out now.” Blue replied quickly, “Go to it.”
Though he was the most famous officer in the Service, Blue was not the unanimous choice to lead it. Several high-ranking officials lobbied instead for Joseph White, the senior officer to whom Wyman had first turned when he removed Joseph Kinyoun from San Francisco, to take the helm. Each man had his supporters: White was seen as the better pure doctor; Blue, the more collegial. President William Howard Taft, then in his second year in office, was left to make the decision, and joked with reporters that he would have to pick his favorite color.
In the end he was swayed by Blue’s record of twice eliminating plague from San Francisco, a job that White had called impossible. Blue was told to return from Hawaii and make his way to Washington, where he met with the president at the White House. Shortly thereafter, Taft announced that at the age of forty-six Blue would become the nation’s fourth Surgeon General, heading an agency whose name would now be simply the U.S. Public Health Service.
The scope of the job was staggering. Blue, who had never overseen more than a dozen officers at any one time, stepped into the top seat of a bureaucracy encompassing a staff of more than a thousand, ranging from pharmacists to nurses to engineers. Simply listing his responsibilities required a map of the world. He was in charge of 50 quarantine stations along the U.S. coasts, 120 medical relief stations spread from Japan to Africa, a leprosy treatment center in Hawaii and a tuberculosis sanitarium in New Mexico. The geography of the job was one thing; its new sense of purpose another. As part of the restructuring that included the name change, the Service’s mission had been expanded to include not just infectious diseases like cholera and plague but “all diseases of man,” a nod toward the optimism that pervaded medicine at the time. Sanitation, bacteriology and the development of the first modern drugs had made it seem possible that life would one day be if not eternal then something close to it. Blue’s agency was expected not only to prevent epidemics of virulent disease from surfacing in America but to attend to anything that could improve the nation’s quality of life.
In his first years in the job, Blue directed investigations into pollution in drinking water, oversaw an expansion of worker safety laws, pushed for more stringent milk pasteurization codes and blocked the sale of so-called “cure-alls” by charlatans who claimed that their secret mixtures could succeed where other medicines had failed. To strengthen the trust between patients and doctors, he lobbied the American Medical Association to adopt a new code of ethics which stated in part that “it is unprofessional to promise radical cures; to boast of cures of secret methods of treatment or remedies,” a creed credited with professionalizing the ranks of doctors. He fought typhoid fever in Iowa and Virginia, smallpox in Kentucky and dengue fever in Florida, and organized the first meeting held in the United States of the International Congress on Hygiene and Demography, which brought thirty-three nations to Washington to share their successes in what was then being called the Sanitary Movement.
The gathering, the largest of its kind, showed the first glimpses of a future in which human life was expected to be long and meaningful. The attendees were nearly all born in the harsher world of the nineteenth century, when rudimentary care and poor sanitation led many parents to bury their children before they reached adolescence. Educators demonstrated the benefits of schools with more natural light; hospitals gave seminars on how teaching mothers to care for their infants improved mortality rates; sanitariums built scale models showcasing the use of calming colors and bubbling fountains in rooms dedicated to the treatment of the mentally ill, a break from the metal cages that some psychotic patients were locked inside just a generation before. In addition to leading the conference, Blue spoke to packed audiences about how his rat eradication campaign had not only eliminated plague from San Francisco but cut down on the spread of illness overall.
He made time for more pedestrian health matters, too, by installing drinking fountains in government buildings in Washington to prevent the use of shared cups that easily spread disease. Concerned about the growing prevalence among poor Southerners of pellagra—a painful skin disease that progresses from diarrhea to skin lesions to dementia and death—he established the Spartanburg Pellagra Hospital in South Carolina, the nation’s first clinic devoted to studying the effects of the disease. He asked Dr. Joseph Goldberger, then known as one of the Service’s best officers in the field of infectious disease, to search for its root cause.
At th
e time, most doctors considered the disease the result of a parasite, though it had never been identified. Goldberger, however, was struck by the fact that doctors and nurses who treated pellagra patients never fell ill themselves. Its victims were overwhelmingly concentrated among poor sharecroppers and African Americans who ate filling but nutrient-poor diets consisting mostly of corn. Sensing that the cause was nutrient deficiency, Goldberger ran experiments at orphanages in which he discovered that giving children milk and eggs in addition to their standard meals resulted in fewer cases. Other tests soon revealed that adult patients with the disease who were given more balanced diets including turkey, chicken and green peas almost universally recovered. When skeptics argued that diet alone could not prevent the disease, Goldberger injected himself with blood and other bodily fluids from patients, proving that it was not transmissible. Though he would not live to see it, later experiments proved that the disease was caused by a lack of niacin, a common B vitamin.
Uninterested as he was in power or glory, Blue was the opposite of what the Service had long expected from its Surgeon Generals. Gamesmanship and political maneuvering remained foreign to him, and he exhibited a humility and earnestness that often felt out of place in Washington. Where Wyman had valued control, Blue knew that his talent lay not in his scientific certainty but in his willingness to listen to others, and was content to let others take the reins where warranted. The effect was an immediate boost in the agency’s morale, leaving one doctor to credit Blue with fostering “the spirit that makes every man on the corps go where he is ordered on a minute’s notice and put in twenty-four hours a day instead of the regulation seven whenever there is the slightest public reason for it.” His reputation grew so high that he was nominated president of the American Medical Association, the first time that the Surgeon General had also headed the largest organization of private physicians in the country.
The demands of Blue’s dizzying schedule began to manifest themselves in his body, turning the boxer’s build that he had long prided himself on into the wide frame more common among men of his stature who were approaching the age of fifty. He lamented the amount of time he spent shuffling between meetings in Washington, a life so different from the solitary, peripatetic lifestyle that had become second nature to him. “All seasons and days are alike to me,” he complained in a letter to his sister Sallie.
When given an opportunity to rejoin the front lines he took it. On July 28, 1914—the day that Austria–Hungary declared war on Serbia, effectively starting the First World War—a forty-nine-year-old Swedish sailor by the name of Charles Lundene died in an isolation ward at Charity Hospital in New Orleans after developing a high fever and dark, swollen glands on his groin. An autopsy confirmed doctors’ suspicions: the body was bristling with plague, making Lundene the first known person in the eastern half of the country to die from the disease. A second victim was discovered the next day, prompting the mayor to request help from Washington to quash what looked like the beginning of an epidemic.
Blue ordered Rucker and a team of men who had worked with him in San Francisco to report to the city and boarded a train himself, arriving in the city two days later. There was little time to waste. New Orleans was the gateway for all traffic up and down the Mississippi, connecting the farms and factories of the Midwest with ports around the world. Infected fleas that jumped onto a rat hiding on a ship heading northward could spread the disease to Memphis, St. Louis and St. Paul within a week. If the outbreak was not contained quickly and it was necessary to impose a quarantine, then the country’s chief connection to the Panama Canal—scheduled to open in less than a month—would be shuttered, denting its economy at a time of war.
In the first hours of the outbreak, Charity Hospital was evacuated and its patients sent into quarantine at a former plantation north of the city. Health officials then dragged all of the furniture outside and burned it in a bonfire on St. Joseph Street. Patients who were suspected of developing plague were isolated and injected with a newly developed anti-plague serum that seemed to shock the disease out of the body, leaving one man who received an injection after his fever spiked to 108 degrees soon shivering with a 96-degree chill that required nurses to replace ice packs around his body with hot water bottles.
Once Blue arrived, he set up a laboratory next to City Hall and followed the same script which had helped save San Francisco. He dispatched more than 350 ratcatchers across the city, while paying special attention to the Stuyvesant Docks off of Tchoupitoulas Street, where shipments of grain from the Midwest attracted thousands of rats. Every rodent that was caught was brought back to Blue’s laboratory, where it was tagged with the location and date of its capture and autopsied. Blue went through the city, identifying all of the ways in which it harbored the animals. Outhouses and backyard chicken coops were torn down; homes were raised off of the ground; layers of concrete were laid underneath sidewalks and buildings.
Blue spent two months in New Orleans, enough time to ensure that there was no widespread outbreak. He then traveled to New York, Philadelphia and other major cities along the East Coast, implementing rat-proofing measures in hopes of preventing plague from nestling into the densest urban centers of the country. In Philadelphia, public health officials offered bounties of five cents for every live rat—and two cents for a dead one—brought to a receiving station at the Race Street pier and posted handbills around the city urging residents to “Kill The Rats—And Prevent the Plague.” “Every one of our seaports is now menaced by this frightful disease,” Blue told the New York Times.
He continued to direct New Orleans’s rat control campaign from Washington. After discovering that the Egyptian rat, a species known for its climbing ability, was more common in the city than the Norway rat he had encountered in San Francisco, he ordered homes and businesses to insert a layer of metal in their roofs, preventing rodents from eating through the ceiling in search of food. He had signs hung up around the city depicting cartoon rats in top hats and tuxedos feasting out of an uncovered trash bin underneath foot-high letters asking, “Is Your House Rat Proof?” In the eighteen months that Public Health Service officials were in New Orleans, they killed and autopsied nearly 375,000 rats, a sum almost equal to the total human population of the city. Approximately thirty people developed plague, ten of them fatally.
Though his work to combat plague kept him consumed with what he considered a disease of the past, Blue continued to look toward the future. The new era of medicine that the Public Health Service was helping usher in was taking medical care out of the home and the offices of country doctors and centering it on the hospital, an institution that until the end of the nineteenth century was considered the last resort for those who had no means or family to support them. Procedures that would have seemed nothing short of fantasy a generation before were performed daily in urban operating rooms, drawing on sophisticated technology that felt otherworldly to patients whose parents had largely lived by candlelight.
The danger in such a rush of invention was that not all Americans would benefit. Blue, unable to forget his sisters in Marion to whom he continued to send monthly checks, began advocating for a national system of health insurance to bring the wonders of the modern era within the reach of poor farmers and factory workers who were the most likely to be exposed to illness. “There are unmistakable signs that health insurance will constitute the next great step in social legislation,” he told a meeting of the American Medical Association in Detroit in June of 1916 to great applause.
Along with legislation, he brought modern medicine and science to areas that had been left behind. In order to let skeptical Americans see it for themselves, he funded a special train that traveled to rural outposts and set up demonstrations of the positive effects of sanitation. One train car displayed models of hygienic toilets; in another, early motion pictures showed how to exterminate rats, mosquitoes and other common carriers of disease. The work served as a useful distraction from the reports detailing the e
ffects of chemical weapons on soldiers in Europe that filtered onto his desk in Washington. “I never thought that I would live to see such a colossal war that is prevailing in Europe,” he wrote in a letter back home. “It is simply barbarous.”
The U.S. entry into the war in 1917 changed the course of Blue’s life. As the first American soldiers prepared to ship out for the battlefields of Europe, Congress debated whether to fold the Public Health Service into the military. Blue offered no strong opinion on the Service’s future, planting seeds of distrust among officers who were put off by what they considered his apathy. The Service eventually remained independent, but further demands from Washington would expose Blue’s weaknesses as a leader.
When the war was over, Congress saddled his agency with the responsibility of caring for returning veterans, but gave it few funds with which to fulfill its new mandate. More than 200,000 wounded and disabled veterans came back from Europe, overwhelming the Service’s ability to provide treatment. Blue ordered rush conversions of underused quarantine stations into veterans’ hospitals, satisfying no one. Complaints about the patchwork system funneled into Washington and continued to grow louder, undercutting the political capital Blue had acquired. He further distanced himself from power by pushing for an education campaign warning the public that returning soldiers could spread venereal disease. Though medically responsible, it was canceled by President Woodrow Wilson, a prim former college professor who took office in 1916 after a long career focused on extolling the influence of the Puritans on American culture.
Distracted by his responsibility to provide care for veterans, Blue neglected the original mandate of the Public Health Service. An outbreak of a deadly strain of influenza, known as the Spanish flu, emerged in March 1918 and spread quickly across the country. The disease, the first serious flu epidemic to emerge in the United States in more than twenty-five years, seemed to prey upon young, healthy adults, as if intent on erasing a generation.