The American Plague by Molly Crosby

Accounts of mankind's endless effort to combat disease are fascinating to me. A good medical history weaves together the scientific discovery of the illness, the social history of its effect on humanity, and the biography of the men and women who devote their lives to fighting it. Several months ago I read David Oshinsky's Polio, which traces the race to a vaccine between Jonas Salk and Albert Sabin, and enjoyed it greatly.

In The American Plague, Molly Crosby traces the history of another viral disease, yellow fever. Though little known by most Americans today, this is a disease with symptoms horrific enough to match anything else nature has thrown at us:

It hit suddenly in the form of a piercing headache and painful sensitivity to light, like looking into a white sun. At that point, the patient could still hope that it was not yellow fever, maybe just a headache from the heart. But the pain worsened, crippling movement and burning the skin. The fever rose to 104, maybe 105 degrees, and bones felt as though they had been cracked. The kidneys stopped functioning, poisoning the body. Abdominal cramps began in the final days of illness as the patient vomited black blood brought on my internal hemorrhaging. The victim became a palate of hideous color: Red blood ran from the gums, eyes and nose. The tongue swelled, turning purple. Black vomit roiled. And the skin grew a deep gold, the whites of the eyes turning brilliant yellow.

It doesn't get much nastier than that. Crosby devotes the early chapters of the book to one of the largest modern outbreaks of yellow fever, the 1878 epidemic in Memphis, Tennessee:

The city collapsed, hemorrhaging its population, its income, its viability. Trains pulled away, leaving people weeping beside the tracks, their last chance at escape gone as the final train cars rolled to a start. A morbid calmness fell over Memphis, so still and quiet as to be serene if one didn't know it was simply the pallor of death. In July of that year, the city boasted a population of 47,000. By September, 19,000 remained and 17,000 of them had yellow fever.

Crosby then shifts her focus to Cuba, twenty years later, and the bulk of the remaining pages are devoted to the efforts led by Army doctor Walter Reed to isolate the causes of yellow fever. The disease had hit the American military hard during the Spanish-American War, and Reed was dispatched to Cuba to lead a team to investigate the disease.

As Walter Reed's group began to narrow their focus to the mosquito as a likely vector for the disease, they needed experimental data to support this hypothesis. It had been twenty years since Dr. Carlos Finlay was widely mocked for his mosquito theory, and in the interim a bacterial theory of yellow fever had gained support. Crosby devotes a short chapter to vivisection, human experimentation, and the antivivisectionist movement, and later provides some context about the young men, mostly soldiers, who answered the Yellow Fever Commission's call for volunteers:

In modern times, it's hard to understand the mentality that would lead a soldier into knowingly risking his life for the purpose of medicine. Soldiers are trained to fight and defend; if any illness befalls them, it's considered a cruel and unjust turn of events. But prior to World War II and the introduction of penicillin, soldiers lost their loves to disease far more than bullets. From the time of the American Revolution through World War I, a soldier knew his odds of dying from dysentery, cholera, typhoid, smallpox, influenza, or yellow fever were greater than those on the battlefield, so volunteering for human experiments might not seem as much of a psychological departure as it would today. After all, a soldier's duty is to defense, and many men felt that the greatest threat to the American people lay not in enemy warships or troops, but in disease.

In the Commission's work, there were two parallel experiments. The first was to prove that mosquitoes were the carriers of yellow fever; the second was to prove that simple, unsanitary filth could not spread the disease. The latter would end once and for all the bacterial theory. The first experiment involved, obviously enough, having infected mosquitoes bite the volunteers. The circumstances under which the second experiment was conducted, though posing no risk of a yellow fever infection to the volunteers (or so Reed correctly believed), was immensely unpleasant in its own right:

A single stove stood in the one-room house, and it kept the temperature inside somewhere between 90 and 100 degrees at all times. Impenetrable to light or air, the small room felt like a furnace. The three men began breaking open the crates and boxes left in the center of the room. As they opened the first trunk, the odor was so pungent that the men ran outdoors, hands over their mouths, to keep from retching. After a few minutes, the three men returned and finished unpacking boxes full of soiled sheets, covered in vomit, sweat and feces from the yellow fever ward. They dressed in the filthy clothing that had been worn by dying patients, they covered their cots in sheets stained with black vomit, and then they spent the next twenty nights the same way.

This horrific experience was endured by multiple trios, but not a single one ever developed yellow fever, providing "irrefutable proof that yellow fever could not be transmitted by 'germs,' infected clothing or air." When the mosquito trials succeeded in infecting numerous volunteers (and killing Jesse Lazear, one of Reed's three colleagues on the Commission), the riddle was solved.

Crosby devotes the last section of the book to the century since Walter Reed's efforts. The good news includes the development of a vaccine. The bad news is that the vaccine is no longer included in many vaccine schedules, and the World Health Organization estimates that 30,000 per year still die from the disease in Africa and South America, and the rest of the world "must still be considered at risk for yellow fever epidemics."

The problem with The American Plague is it is not the book Crosby really wanted to write. A resident of Memphis, it is apparent that the local history explored in the first chunk of the book is her true passion. She goes into great detail about city life, and the doctor, nurses, and citizens who lived and died during the 1878 epidemic. Even the verbose subtitle of the book highlights "the epidemic that shaped our history."

As a result, the subsequent shift to Cuba is jarring. Her take on the Yellow Fever Commission's operation is really just a series of short biographies strung into a narrative. Like she does in the Memphis section, Crosby spends far more time on the people than the disease, and there is no significant effort to explore the scientific and medical underpinnings of the Commission's efforts. The final section, which purports to takes the story to the present day, is a mere 25 pages. Barely five pages are devoted to the development of the vaccine, a few references to the continuing presence of yellow fever in Africa and South America, and then, you guessed it, an epilogue that returns to Memphis for a discussion of the long-term effects on that city.

Crosby has written an excellent long article on the 1878 yellow fever epidemic in Memphis, with a shallow hundred page detour to Cuba tacked on to pad the page length. The narrative is breezy, and the details about Memphis are legitimately interesting, but those seeking a serious scientific history of yellow fever will want to look elsewhere.