Book Review

Plague Ports: The Global Urban Impact of Bubonic Plague, 1894–1901

N Engl J Med 2007; 357:1355-1357September 27, 2007

Article

Plague Ports: The Global Urban Impact of Bubonic Plague, 1894–1901
By Myron Echenberg. 349 pp., illustrated. New York, New York University Press, 2007. $48. ISBN: 978-0-8147-2232-9

When in his medieval masterpiece, The Decameron, Boccaccio pointed his finger at the infidel East as the cause of the “unpleasantness” that sent his storytellers wandering, he expressed the relentlessly popular explanation that epidemic catastrophes were caused by a corrupt “other.” The consequence of this unyielding human prejudice has been unthinkable havoc and injustice imposed on scapegoated populations since antiquity. This was never more brutally the case than during visitations of the disease that defined the term pestilence and was the subject of Boccaccio's epic: bubonic plague.

Myron Echenberg demonstrates in this book that the attitude that prevailed during ancient and medieval plague epidemics did not change when a third pandemic visited port cities across the globe between 1894 and 1901 and continued to run its course sporadically until antibiotics were available in the 1950s. Plague in this modern era reinforced grotesque inequalities that had been produced by global systems of ruthless colonial exploitation. But what Echenberg documents equally incisively is the complex historical dialectic between epidemics and political and social transformation. The third plague pandemic challenged structures of political power and the social relations of governance, undermined and reinforced ruling hegemonies and ideological systems, and opened and closed historical epochs in the various ports in which it docked. The pandemic also inaugurated the scientific discovery of the plague bacillus and the vector of transmission. The latter crucial piece of the puzzle, however, was discovered too late to stop the repeating of mistaken responses to past plague pandemics.

The pandemic began in British-ruled Hong Kong and spread rapidly to other British colonial ports and to port cities where the British dominated trade: Bombay, India; Alexandria, Egypt; Sydney, Australia; Cape Town, South Africa; and Buenos Aires, Argentina. International trade with these cities spread the disease farther, to Porto, Portugal; Rio de Janeiro, Brazil; Honolulu; and San Francisco. The medieval measure of land quarantine, house quarantine, or both was the first resort of both ailing ancient regimes such as the Portuguese monarchy and modernizing positivist dictatorships such as those in Argentina and Brazil. These sanitary cordons were ineffective and eliminated the liberty of the persons under their control to escape danger, to engage in trade, to travel for employment, and ultimately to obtain the necessities for subsistence. Maritime quarantine was often rigorously applied after the disease had already been imported, but it may have prevented the epidemic from finding new havens. The Venice protocol on plague control that was drawn up at the International Sanitary Conference of 1897 blamed the spread of the disease on the traditional British resistance to quarantine. Although Alexander Yersin and Kitasato Shibasaburo identified the bacillus during the 1894 epidemic in Hong Kong and there was widespread recognition that rat epizootics preceded human plague epidemics, the Venice measures still accounted for transmission through “excretions of patients (sputum, dejections), morbid products (suppuration of bubos [sic], of boils, etc.), and consequently by contaminated linen, clothing, and hands.”

Echenberg emphasizes, however, that no international consensus emerged during the pandemic, and he critically compares emergency public health strategies and the complex web of interests that gave rise to them in each of the cities the disease visited. British rulers in Hong Kong and India imposed disinfections, compulsory isolation of patients, and destruction of corpses, with indifference to the profanities these measures might constitute for the cultures they oppressed and exploited. They equally ignored the licensed violence and extortion that were practiced by the military and police forces that implemented these measures. Despite the modernist goals of positivist dictators in Argentina and Brazil, the public health authorities in Buenos Aires and Rio de Janeiro were indifferent to the emergent bacteriologically informed paradigm of public health control that might have led them to cull rats and use new vaccines and serums. In Portugal, bacteriologists and humoralists battled over strategy, but across the Mediterranean, public health leaders in Alexandria recruited the cooperation of their diverse populations through a harmonious resolve between Islamic and European interpretations of the disease and its significance. When a change in wind direction created an inferno that razed the entire area, the residents of Honolulu's Chinatown paid a devastating price for the sanitary tactic of fire-purging that was ordered by the U.S. officials who dominated the governing elite of Hawaii.

Fighting the Bubonic Plague in the Chinese and Native Quarters, Honolulu.

It was in Sydney in 1900 that applied epidemiology was used to anticipate the biologic confirmation of vector transmission and where a new model of public health control of bubonic plague was most successful in containing an outbreak. There the chief medical officer, John Ashburton Thompson, combined traditional quarantine and isolation between patients and contacts with the widespread use of the new Haffkine vaccine and Pasteurian serum. He also used a new epidemiologic analysis of transmission variables to come to his own conclusion that a specific species of rat flea, Xenopsylla cheopis, was the determining factor in the relationship between animal epizootics and human epidemics. His culling campaign, conducted in the light of this knowledge, contained the outbreak instead of causing an explosion of transmission — a possibility when rats were killed in ignorance of the threat posed by fleas seeking new sources of blood meals after their host had died.

What Echenberg's commanding analysis of this global epidemic highlights above all is that if public health approaches in Alexandria and Sydney that were based on consensus produced cooperative populations in the struggle to defeat plague, attempts at authoritarian imposition elsewhere produced violent social and political conflicts with far-reaching consequences. The failure of the Qing dynasty to support Chinese resistance to British sanitary measures in Hong Kong allowed the British to gain mainland territories, fueling the successful rebellion against Qing rule. British plague controls in India accelerated the growth of nationalist politics, which culminated in India's winning independence. In San Francisco, Chinese elites successfully exploited the idea of American rugged individualism to overthrow public policy that was racially discriminatory and had been imposed in the name of collective rights. Rioters fought public health authorities in South America and toppled an unstable monarchy in Portugal. In South Africa, the boost that the plague gave to segregationists stimulated the creation of the South African Union, which unhinged British dominion over the territory and created new leaders of human and political rights in Africa — foreshadowing the creation of the African National Congress, which would later be led by Nelson Mandela.

Echenberg's richly textured and deeply discerning account of the last plague pandemic is, as he points out, a cautionary tale of the politics of disease control in a globalized world. It should become compulsory reading for all who are engaged in the construction of the new discipline of global public health.

Dorothy Porter, Ph.D.
University of California at San Francisco, San Francisco, CA 94143