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Musings of a Cancer Doctor

Epi Stories

Sledge, George W. Jr. MD

doi: 10.1097/01.COT.0000669704.77455.44
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pandemics in history
pandemics in history:
pandemics in history
George W. Sledge, Jr., MD
George W. Sledge, Jr., MD:
GEORGE W. SLEDGE, JR., MD, is Professor of Medicine at Stanford University. He also is Oncology Times' Editorial Board Chair. His OT writing experience has been recognized with an APEX Award for Publication Excellence and a FOLIO: Eddie Honorable Mention Award. Comment on this article and previous postings on his OT blog at bit.ly/OT-Sledge.

“When they come to write the history of this epidemic, what do you think they'll say?” asked my brother Jeff when we spoke recently.

His question got me thinking about epidemiology stories I've heard over the years. Epidemics often have key stories attached to them. These stories become shorthand for the meanings we derive, or at least for the memories we retain across time. Let's call them Epi stories.

The first use of the word itself, from the Greek epi (on) and demos (people) comes from Homer. In Homer's Iliad, Agamemnon, leader of the Achaeans in their war against Troy, robs the temple of Apollo and kidnaps the daughter of the priest Chryses. In response to Chryses' prayers, Apollo sends a plague to the Achaeans, sickening them as they waited in their ships on the shores near Troy. If this sounds familiar, think of the role cruise ships (where crowded groups shared and spread COVID-19) played in the early part of the current pandemic. “On the people,” indeed. Hippocrates used Homer's word to describe outbreaks that occurred intermittently to populations, a case of science taking its clues from literature.

The Iliad is only the first in a long line of creative works devoted to epidemics. Thucydides' History of the Peloponnesian War has an extensive section devoted to the epidemic that ravaged Athens, fatally weakening the first democracy and taking the life of its great leader Pericles. Giovanni Boccaccio's Decameron, written just a few years after the Black Death killed half of Europe, follows 10 sexy young people “sheltering in place” in a Florentine villa while telling great stories. Daniel Defoe's Journal of the Plague Year, written several decades after the last visitation of the bubonic plague on England in 1665-66, is a stunning portrayal of what it was like to live through such an event. Irresponsible Londoners avoided social distancing, bought fake plague cures from con men, and resorted to panic buying. Then, as now, front-line workers “went about their employment with a sort of brutal courage,” to quote Defoe. And, of course, Edgar Allan Poe's The Masque of the Red Death tells of the frightening suddenness with which a crowded banquet room can become the nidus for an explosion of disease, though it is mostly just a great atmospheric horror story.

In more recent times, we have Katherine Anne Porter's wonderful Pale Horse, Pale Rider, a semi-autobiographical fictionalization of what it was like to come down with, and barely survive, the 1918 influenza pandemic. At one point, the protagonist imagines herself fleeing death on her horse:

“Come now, Graylie, she said, taking his bridle, we must outrun Death and the Devil...The stranger swung into his saddle beside her, leaned far towards her and regarded her without meaning, the blank still stare of mindless malice that made no threats and can bide its time...The stranger rode beside her, easily, lightly, his reins loose in his half-closed hand, straight and elegant in dark shabby garments that flapped upon his bones; his pale face smiled in an evil trance, he did not glance at her. Ah, I have seen this fellow before, I know this man if I could place him. He is no stranger to me.”

Nor a stranger to us, now, that mindless malice, that pale face.

My other favorite in modern writing is Albert Camus' The Plague, his great novel in which an epidemic overtakes Oran, killing residents in their thousands and paralyzing civic life. The book is an extended metaphor for World War II and the French resistance to German occupation, an occupation experienced by the courageous young resistant Camus. One of the book's main heroes, Dr. Rieux, tries early in the novel to convince the authorities that this disease must be taken seriously, that this is not business as usual, but to no avail. One of the recurring themes of Epi stories is that we never learn, never deal effectively with epidemic disease until it is upon us, and that is often too late.

The AIDS epidemic, of course, developed its own extensive literature, with works such as Tony Kushner's Angels in America, and a host of novels, and Tom Hanks's Oscar-winning Philadelphia. AIDS was a slow-motion epidemic, and we view it in a different way than an acute outbreak like COVID-19. I've not seen any social stigma attached to coming down with COVID, probably because of its lack of a sexual connotation, though racism has reared its ugly head. Post-AIDS we have Steven Soderbergh's prescient 2011 movie Contagion, where a pandemic begins with a bat zoonosis. Epi stories are as old as Western literature and as new as recent Hollywood blockbusters or Steven King potboilers.

But the Epi stories I like best are the stories doctors share, stories based in the epidemics themselves rather than in some fictional representation. One thinks of that striking moment when the Bubonic plague came to Europe in 1347. A Mongol army, besieging a Genoese trading outpost on the Black Sea, was thwarted by a stout defense and strong walls. That army had brought the bubonic plague from the Asian steppes and was dying outside the walls. And then some Mongol commander had the clever idea of catapulting dead plague victims into the fortress.

In no time at all, the defenders started to die of the Black Death. Genoese businessmen packed up their goods, got on their ships, and fled, carrying the plague bacillus with them to Constantinople and Italy, and eventually throughout the Mediterranean basin and across Europe. A later outbreak eventually reached as far as Iceland.

One Epi story, still important today, is that epidemics love globalization, love long-distance travel. We were fooled by MERS and SARS and Ebola into thinking that these dangerous infectious diseases essentially belonged to other places, even other times, and that we were somehow protected by distance and our way of life. I remembered SARS largely because it briefly struck Toronto and led to cancellation of that year's American Association for Cancer Research meeting. An inconvenience, I thought at the time, and then gave it no more thought. Silly me.

In fact, as the infectious disease community has long known, the modern way of life represents our Achilles' heel: rapid jet-spread of disease across the globe, and fragile global medical supply chains. Wuhan supplied much of the world's N95 masks, and Lombardy the nasopharyngeal swabs used for viral detection, both sent around the world using just-in-time delivery schedules, right up until the moment when those schedules no longer made sense and the nickel-a-mask savings provided by modern globalization vanished. Epidemics have their own deadly ironies.

A favorite Epi story involves John Snow, the intrepid British obstetrician who tracked an 1854 outbreak of Cholera to London's Broad Street Pump. The “Broad Street Pump” metaphor is well-beloved by physicians: when you know the cause of a disease (cigarettes for lung cancer), remove the pump handle (as Snow convinced reluctant authorities to do) and you can end the epidemic.

It's a great metaphor, and worked for cholera, but not for COVID-19. It would work just fine for tobacco-induced diseases, as tobacco is a classic pump handle for lung cancer and emphysema. Or perhaps, as was once suggested, for HIV and the AIDS epidemic. In the “Patient Zero” story, a sexually athletic flight attendant spread the disease across the world, a potent meme repeated in print and on TV in works such as And the Band Played On. Identify and quarantine Patient Zero and you halt the epidemic in its tracks, before it can—literally or figuratively—take off. Alas, that particular Epi story was wrong: the flight attendant, subsequent molecular analyses showed, was not “Patient Zero,” nor anything close, in the history of the AIDS epidemic.

The older, related Epi story, and also a near universal meme, is that of Typhoid Mary. The Irish immigrant Mary Mallon (foreigners often take the blame for epidemics) was a cook at upper class homes and had a bad habit of infecting her patrons with Typhoid fever. Eventually identified as a recurring source of disease outbreaks, she was quarantined for almost 3 decades by New York Health authorities. We're currently wrestling with issues related to COVID-19 super-spreaders, of asymptomatic carriers (as was Mary) and with issues of re-infection and disease clearance. And, of course, with the tension between public health and individual freedom.

Tracking origins, as the current outbreak shows, can be hard: we think COVID-19 started in a bat and then somehow migrated through the Wuhan wet market into the Chinese population, but even this is somewhat fuzzy. The idea that it started in a laboratory (an American lab if you are a Chinese fantasist, a Chinese lab if you are an American one) seems ridiculous. And it's hard to remove the pump handle when nature is full of pump handles, or “Patient Zero”/“Typhoid Mary” disease vectors. There are lots of animal viruses patiently waiting their turn to enter the human population, and with COVID-19 we didn't identify the infected in a timely enough fashion, due to the CDC's disastrous failure with testing assays.

The more useful Epi story, or at least more useful for the current outbreak, is the Philadelphia Victory parade of 1918. As the Great Influenza epidemic spread across the world late in 1918, public health authorities were faced with stark choices: business as usual or mandatory social distancing. Health authorities in St. Louis shut down the city, while the chief public health official in Philadelphia, a well-meaning physician put in his job by and answering to the local political machine, allowed a World War I victory parade to go forward. A ship from England (ships again!), loaded to the scuppers with the infected, had just docked at the port, and disease carriers were released just in time for the parade. Soon the citizens of the City of Brotherly Love were dying in their thousands. St. Louis was far less affected.

What impresses, at least impresses a medical oncologist used to dealing with diseases that develop over years or decades, is the vital importance of timing when one shuts down a city or a country. Too soon, and the economic consequences are devastating. They are devastating even if done right on time, as the collapse of the world economy shows. But too late, and you get Philadelphia in 1918, or Milan or New York City or New Orleans in 2020. Looking at 1918's Philadelphia victory parade, and Mardi Gras in 2020, one can wonder how far we have actually come in learning the meaning of some Epi stories.

We still wrestle with our basic ignorance of the natural history of a new disease, just as our ancestors did. We still have to learn and act on the fly, based on incomplete information and imperfect models. We still have decisions made by politicians who seem inherently suspicious of science, or worse, feel the need to politicize every public health action, as if coronavirus actually cared what political party one subscribed to. Despite ample warning from public health officials, we still managed to be woefully unprepared to provide basic medical necessities to health care workers and patients.

We still, or a substantial number of us do, view these outbreaks as supernatural occurrences, and assume that the deity will protect us if we are sufficiently virtuous, so that it is appropriate to avoid social distancing guidelines on Sunday morning. We seem unable to put aside our petty nationalism in the face of global medical and economic catastrophe. Deep inside us, I'm forced to conclude, lurks an atavistic medieval mindset. And that frightens and appalls me. Pandemics bring out the best in some of us—ER docs and ICU nurses—but some of the worst in others.

So, to answer my brother's question, when they come to write the history of these times, when they tell new Epi stories, the stories will be the same old ones. I hope, dear readers, that we all remain healthy long enough to share them.

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