quarantines and travel restrictions against Asians, while supported by his superiors, were crude and discriminatory tools. Moreover, we now know that, even if the courts had not overturned them, such measures would not have stopped bubonic plague. Wounded and uncomprehending, Kinyoun quit San Francisco, and shortly afterward, the public health service. His career on the national stage was over, and its premature end was a reminder that science without compassion is a dry and punitive discipline.
After leaving San Francisco in 1901 at age forty, Kinyoun returned to the East and worked as director of a company making vaccines and antitoxins, as a professor of bacteriology and pathology at the George Washington University School of Medicine, and as the city bacteriologist of Washington, D.C. During World War I, he served the U.S. Army as an expert epidemiologist. Not long after the armistice, however, Kinyoun developed an aggressive lymphoma of his neck. In 1919 at age fifty-eight, he died.1
History has been kinder to Kinyoun than his contemporaries were. For his founding role in the National Hygienic Laboratory, forerunner of the National Institutes of Health (NIH), he is posthumously recognized as the first director of the NIH. It was the work of his youth—applying the powerful tools of bacteriology to the diagnosis of infectious disease—that survives him, untainted by the political and racial poison that infected so many people in 1900.
Rupert Blue, who leapt from San Francisco to the surgeon generalcy, fared far better. To some degree, history favored his endeavors. Just when he took command of the situation in San Francisco, medical science finally grasped the facts about the transmission of bubonic plague. And it was Blue who put those findings into practice in San Francisco. Once rat fleas were identified as the primary culprits, Blue could spare people the ruinous consequences of quarantine, and focus on killing rats.
The personae of Kinyoun and Blue are a study in the making or unmaking of an effective public health leader. Kinyoun had the science and the intellect, but he lacked human relations skills as well as a vision of what public health could bring to suffering populations. Whatever his private feelings about race, Blue did not antagonize San Francisco’s long-suffering minority community. And despite his professed phobia for public speaking, Blue possessed the polish and charm to engage the public, to persuade, to educate, to galvanize change in the field of public health. More than that, he had a populist vision of harnessing public health, not just to lock out epidemics at the border, but to alleviate suffering and improve the life of the people.2
However honeyed his style, his leadership wouldn’t have worked had not Blue, the pugilist, known when it was time to take off his gloves. As historian Guenter Risse has said, “Friendly persuasion was reinforced with intimidation.” It was only when he threatened the feckless city with loss of the Great White Fleet that Blue “fully engaged the powers of his office” as commander of the plague campaign.3
As the sanitarian who liberated San Francisco from bubonic plague in 1908, Blue gained a reputation for the kind of vigorous epidemiology the country needed. He served as the country’s surgeon general from 1912 to 1920, a period when world conflict and vast migrations of soldiers once more carried diseases around the globe. During World War I, Blue fought the twin epidemics of influenza and venereal disease. Although the AMA in 1915 named him the doctor who did the most good for humanity, his legacy was damaged by global events over which he had little control. Saddled with that nightmare of all reformers—an underfunded congressional mandate—he struggled to convert hospitals nationwide into veterans medical centers with too little staff and money to do the job. Had he been a tougher politician, he might have managed it, but it’s likely no administrator could have met all the demands of postwar civilian and military health. Under such pressure, Blue’s dream of a third term devoted to national health insurance died. His goals of mandating universal milk pasteurization and a network of child health clinics were dashed as well. By 1920, Blue was out, his public health vision outdated and undone by a welter of political forces. He remained in the public health service as an assistant surgeon general, serving in domestic plague outbreaks and in international health conferences.
Despite years spent purging plague on the San Francisco Bay, Blue had failed in all attempts to push his victory beyond the county line. For years, he had warned Washington about the danger of plague spreading to squirrels in the countryside. He had implored Washington for men, tents, rifles, and traps to rout the rural infestation. But his requests were deferred or denied. By the time he got approval to send a force into the East Bay, it was too late. Plague had spread to wildlife over thousands of square miles of California hills and grasslands.
It didn’t stop at the East Bay hills, but spread eastward, over the Sierra Nevada mountains and into the Rocky Mountains. In each zone, the fleas found a new host animal, jumping from rats to ground squirrels, then to the golden-mantled squirrels of the Sierras, then to chipmunks and prairie dogs who inhabit villages of burrows throughout the Southwest. Plague’s natural reservoir has always been rodents, and it found a home in the wildlife of the American Southwest, where it still smolders a century later.
Today, pockets of wild plague are scattered over vast territories around the globe. Colby Rucker’s 1909 plague map, with its P-shaped stain over California, has grown into a thick band of plague that covers the western third of the United States from the Rockies to the Pacific. Around the world, plague is scattered widely across Eurasia, Africa, and the Americas. Over the last five decades, the World Health Organization has monitored plague reports from thirty-eight countries, including notification of over eighty thousand cases and almost seven thousand deaths. Seven countries experience plague cases almost every year: Brazil, Congo, Madagascar, Myanmar, Peru, Vietnam, and the United States.4
Modern plague scientists from the U.S. Centers for Disease Control and Prevention (CDC)—men and women who are heirs to Rupert Blue—run a surveillance station in Fort Collins, Colorado. While the disease is considered too deeply embedded in the wild to be eradicated, the CDC and state health departments monitor wildlife, control fleas, and report to the WHO. When plague levels rise dangerously high, they post warnings to protect hikers and campers and sometimes even close state parks until the danger subsides. Warning signs showing a squirrel inside a red circle with a diagonal slash are a common sight in parklands throughout the West.
Such vigilance doesn’t prevent about a dozen people in the United States from contracting bubonic plague every year. Hunters, trappers, campers, and country dwellers are at the greatest risk. The expansion of residential development into the high deserts and foothills of New Mexico, Arizona, Colorado, and Utah brings people closer to plague country. Cats and dogs exploring infected burrows can pick up fleas and become a link between infected wild rodents and people. From 1977 though 1998, twenty-three people contracted plague from sick cats. Five of them died, casualties of misdiagnosis or delayed treatment.5
For patients today, modern antibiotics render the plague far less deadly. A course of intravenous streptomycin or other antibiotic offers most people a ready cure. But its efficacy depends on a swift diagnosis and timely treatment. Doctors in the Southwest are acutely aware of what a sudden attack of swollen glands and fever can portend. Such knowledge has saved scores of people in recent years. One of them was Debra Welsh.
Right before New Year’s Day 2000, the forty-three-year-old woman, who lives in the country north of Albuquerque, New Mexico, noticed that her house was invaded by little drunken, wobbly mice. She caught the mice in her hand, holding them with a paper towel. She flushed them down the toilet and washed her hands with antibacterial soap. Later, odd symptoms emerged.
A swollen lymph node appeared. The chills began. Intense aches and back pain hinted of something more grave. Following admission to St. Joseph’s Hospital, she was diagnosed with bubonic plague. A course of twenty- first-century antibiotics saved her from a medieval fate.6
A century after its discovery, untreated plague remains one of the most deadly diseases known to humankind. Without treatment, the mortality of bubonic plague ranges from 50 to 70 percent. When untreated plague spreads to the lungs or bloodstream—as pneumonic or septicemic plague—the mortality rises to nearly 100 percent.
Since plague is so lethal, San Francisco was lucky to have only 280 reported cases. Some people might wonder whether this represented a real epidemic. Kenneth Gage of the Centers for Disease Control and Prevention says the answer is yes. An epidemic is defined as any increase over the normal, baseline incidence of a disease. Before 1900, plague had no normal incidence in the Unites States. The San Francisco plague cases represented the first known outbreak in the continental United States. From that outbreak, plague established a foothold across the western states. Today, despite preventive vaccines and antibiotics, plague occurs in roughly a dozen people a year. Even forty cases of bubonic plague in any twenty-first-century American city would be considered an epidemic and an emergency. So 280 confirmed cases and 172 deaths certainly qualifies.
“San Francisco was clearly an epidemic,” confirms Gage—no relative of the old California governor. “We would go crazy if we had that number of cases right now.”7
Gage is a plague expert with the CDC in Fort Collins, Colorado. As an authority on the odd parasitic
