When Germs Travel: Six Major Epidemics That Have Invaded America Since 1900 and the Fears They Have Unleashed

John S. Marr, MD, MPH


October 18, 2004

By Howard Markel
Pantheon Books
Copyright 2004
263 pages
ISBN: 0-375-42095-9
$25 hardcover

When Germs Travel: Six Major Epidemics That Have Invaded America Since 1900 and the Fears They Have Unleashed is a collection of little-known medical accounts of epidemic disease threats in America. It should interest both a lay readership and health professionals who enjoy historical infectious disease arcana. The book also provides a provocative opinion on past and present-day methods to prevent and control disease spread.

Howard Markel, a pediatrician and medical historian, has selected 6 events that he contends demonstrate a continuing pattern of discriminatory governmental responses to epidemic threats over the last century: outbreaks of tuberculosis, plague, trachoma, typhus, HIV/AIDS, and mysterious gastrointestinal symptoms. The subtitle of the book, which refers to 6 major epidemics, however, may be misleading. Although the first 5 of the importations (tuberculosis, plague, trachoma, typhus, and HIV/AIDS) may fit into the theme of true threat, it is difficult to rationalize the last, an isolated 1997 cluster of diarrheal disease in Detroit, Michigan, as a "major epidemic." Nor did it unleash major fear. In this last incident, Markel found himself volunteering at Freedom House in the slums of Detroit when a recently arrived refugee developed explosive gastrointestinal symptoms; he made a tentative diagnosis of cholera, and for him, the fear must have been quite real. (It later turned out to be rotaviral infection.)

Markel does, however, use singular accounts to movingly describe the plight of countless immigrants and aliens who have been caught in a Kafkaesque morass of poverty, insensitivity, and bureaupathy. Markel's experience at Freedom House is in this way similar to the 5 other epidemic diseases chosen, and the author is clearly an advocate for those who were victimized by the events. His characters are personalized and put into an historical context of contagion and how it was dealt with by physicians and public health officials. In the 1990s in New York City, one Ecuadorian patient and one Ethiopian patient describe how they confronted the diagnosis of tuberculosis; in turn of the century San Francisco, California, the Chinese community is quarantined by an officious health department; in 1916, an immigrant Russian rabbi is detained at Ellis Island and undergoes gruesome treatment for trachoma; a year later in Texas, due to fear of epidemic typhus, Mexican day laborers undergo hazardous decontamination procedures for lice; and another episode deals with the more recent stigmatization of Haitians in the early days of the AIDS epidemic.

Each of these incidents is discussed in a larger historical context of discovery, allied diseases, distribution and spread, and the early, often draconian attempts at prevention and control. It is likely that Markel, who also has written Quarantine! (about typhus and cholera epidemics in late 19th-century New York), did not wish to retell stories from his previous book.[1] However, even brief allusion to these quite real disease threats would have demonstrably bolstered his premise that individual and systematic xenophobic discrimination follows the same path as epidemic disease. Indeed, the common thread of When Germs Travel is that immigrants and aliens have been unfairly discriminated against in the 1900s by a specter of infectious disease that seemed to generate a tribal response, fogging otherwise rational and finite decision making. This irrational, aggressive response to contagion is not new to the history of infectious diseases, but Markel points out that it is still with us, even now at the beginning of the 21st century.

Curiously omitted is a reference to a recent medical historian's work on the archetype of this kind of prejudice: Mary Mallon.[2] This Irish-Catholic cook was forcibly hospitalized for years by an authoritarian New York City Health Department and labeled "Typhoid Mary" by scabrous tabloids. It would also have been worthwhile had the author elaborated on the 2003 SARS pandemic that originated in China, and the public, media, and the global governmental responses to it. This was certainly a massive epidemic, unleashing both fear and a threat of foreign importations. However, with the mutual cooperation between governments and the use of traditional methods to limit spread, SARS was checked with a minimal minority-bashing or scurrilous reporting.

Another recent book on the San Francisco plague years supports Markel's view on the limitations of quarantine.[3] Markel describes Joseph Kinyoun's failed measures to contain the disease; however, he does not mention Dr. Rupert Blue's subsequent program of sensible containment. Another possible omission that Markel makes is poliomyelitis; although not an "imported" disease, early epidemiologic investigations theorized that the disease was transmitted by house flies from foreigners' filthy hovels to wealthy homes.

When Germs Travel is not as exhaustive as another recent book criticizing the shortcomings and failures of public health,[4] but the author has chosen to focus on dated and draconian intervention strategies. Markel writes: "Quarantines, cordons sanitaires, immigration depots, and long inspection lines all represent a past era's responses to the containment of contagion. Today, these antiquated approaches are no longer up to the job" (page 209). Perhaps they are not, but one may posit that they worked for SARS (thus far), and newer American Civil Liberties Union (ACLU)-friendly SARS and Pandemic Flu isolation and quarantine measures have been developed. These will be used in the future until such a time that the world's wealthy nations agree to a suggestion that they "devote at least one-tenth of one percent of their gross national product towards funding the proposals of the United Nations" (page 213). This may be an ideal solution, but unlikely to occur in the near future, given real-world constraints.

Whether one agrees with the author or not about what may best be done today, the stories and intrigues, such as the 6 vignettes, of When Germs Travel remind us of our many past mistakes. Additional insights and observations by authors, such as Howard Markel, are needed to research, distill, reference, and entertainingly inform us of other medical foibles. He reminds us of the Hippocratic warning: "As to diseases, make a habit of two things -- to help, or at least, to do no harm" (page 140). Hopefully, present public health policies will help policy makers and minimize harm as they address future pandemics.


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