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Six major epidemics that have invaded America since 1900 and the fears they have unleashed

Written by Howard MarkelAuthor Alerts:  Random House will alert you to new works by Howard Markel


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On Sale: January 21, 2009
Pages: 288 | ISBN: 978-0-307-49307-1
Published by : Vintage Knopf
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The struggle against deadly microbes is endless. Diseases that have plagued human beings since ancient times still exist, new maladies like SARS make their way into the headlines, we are faced with vaccine shortages, and the threat of germ warfare has reemerged as a worldwide threat.

In this riveting account, medical historian Howard Markel takes an eye-opening look at the fragility of the American public health system. He tells the distinctive stories of six epidemics–tuberculosis, bubonic plague, trachoma, typhus, cholera, and AIDS–to show how how our chief defense against diseases from other countries has been to attempt to deny entry to carriers. He explains why this approach never worked, and makes clear that it is useless in today’s world of bustling international travel and porous borders.

Illuminating our foolhardy attempts at isolation and showing that globalization renders us all potential inhabitants of the so-called Hot Zone, Markel makes a compelling case for a globally funded public health program that could stop the spread of epidemics and safeguard the health of everyone on the planet.


Chapter 1

ONE: Facing Tuberculosis

One afternoon a month and a day after the terrorist attacks on the World Trade Center and the Pentagon, I was in a crowded subway car making its way down Manhattan's Upper West Side. Only seven miles south of the 125th Street station, where the train was delayed temporarily, rescue workers and firemen were searching through the rubble and carnage of September 11, 2001. Yet on the subway that afternoon-and around the country-a different form of terror was on our minds.

Directly above me on both sides of the train were bright posters advertising a new and improved detergent that "eliminates 99.9% of all bacteria lurking in your clothing." (Parenthetically, all soaps pretty much accomplish this task.) Sitting next to me was a heavyset woman rubbing her hands over and over like some modern-day Lady Macbeth. Only instead of washing off the blood of her royal rivals, she was slathering her hands with a pinkish red anti-bacterial moisturizer "guaranteed to both soften the skin and rid you of nasty germs." Seated next to her were two older men who appeared to be breathing less deeply and far more rapidly than I suspected they might otherwise be doing. At the very end of the car was a young woman wearing a surgical mask and rubber gloves.

If these signs were not enough to alert the casual observer to what was going on, all one had to do was glance at the newspapers many were reading. Every publication, from the lowly tabloids to the august New York Times, screamed the same headline in bold print: ANTHRAX! Inside their pages were all the sordid details of the infection-laden letters sent earlier that week to Senator Tom Daschle and others. That very morning, an assistant to NBC anchorman Tom Brokaw, who received a similar missive in late September, was confirmed to have a bona fide case of cutaneous anthrax.

In the weeks that followed, several more cases of anthrax popped up, some easily explained (such as those among the postal workers handling the tainted mail) and some not (such as the fatal case in an elderly woman from Connecticut whose mail was, unluckily, mixed in with contaminated envelopes meant for others). And we all worried if the Pandora's box of germs that appeared to have been opened by terrorists would ever be closed. The sudden appearance of a frightening, infectious agent was, perhaps, one of the few things that could have so successfully taken the nation's collective mind, albeit temporarily, off the stunning events at ground zero. Government officials searched to find the source of the infection, to the accompaniment of television pundits pointing fingers and calling our public health mechanisms inadequate. Sales of Cipro, one of several antibiotics effective against anthrax (and by far the most expensive), went through the roof. Emergency rooms and clinics across the country were inundated with people wondering if every scrape, wheeze, or contact with something as harmless as the crumbs of a powdered sugar doughnut was an incipient case of anthrax.2

That the public would focus with a laser beam intensity on anthrax, a strange scourge that killed only a few in spectacular fashion, while paying little attention to the more common contagions that literally plague us on a daily basis, is a phenomenon hardly unique to our era. Healthy human beings frequently worry more about frightening, unexpected infections than about diseases we know all too well, such as tuberculosis, a disease that is slow and patient, relentless and effective, and year in, year out, sends millions to their graves.3 If the forces of evolutionary biology could have imbued the tuberculosis germ with the capacity to feel neglect, it was probably used to it by now.

Today, more than 2 billion of the planet's 6 billion people are infected with the latent form of tuberculosis. In the United States alone, 10 to 15 million are infected with it. Of this multitude, at least 10 percent of them will go on to develop the active form of tuberculosis sometime during their lives. The period between latency (with no signs of disease at all except a positive TB skin test) and active illness can range from weeks to years after the microbe Mycobacterium tuberculosis settles into the human body. Much has to do with the health of the particular host, his nutritional status, living conditions, and the coexistence of other diseases. But when considering the many influences that enable the TB bacillus to transform good health to ill, it is wise to recall the French chemist and microbiologist Louis Pasteur's warning to respect the "infinitely great power of the infinitely small."4

Every year public health officials across the globe diagnose more than 8 million active cases of TB. These are the people who are most infectious to others. The sicker someone is with active TB, the greater the number of microbes in his or her body; and with every cough, shout, or breath, that individual becomes a more significant risk to the public health. The average person with active TB will infect twenty other people before he or she dies or is adequately treated. What surprises many is that during every twelve-month period, about 3 million people die of tuberculosis, making it the leading infectious cause of death in the world today. In fact, more human beings will die of TB in our era than at any other point in recorded history.

The disease, often referred to as the white plague in deference to the infamous bubonic, or black plague, typically strikes adults during their most productive years of life, ages eighteen to fifty-five. Fortunately, since the late 1940s medicine has been blessed with a wide range of potent antibiotics that can treat TB and, in most cases, cure it. At the same time, these medical miracles have given rise to premature declarations of victory over tuberculosis. Especially over the past decade, public health specialists have grown concerned about the rise of multidrug-resistant strains of tuberculosis around the world. In layman's terms, this means that not only do we have deadly germs on our hands, but, in at least one out of ten cases (and far more in Asia, South America, and the former Soviet Union), the mycobacteria are resistant to the very menu of powerful drugs we have developed to enter and kill them.

Only recently have we begun to recognize the folly of extensive funding cuts in tuberculosis surveillance and treatment programs, and the unintended consequences of not investing in the basic health care needs of the most impoverished citizens of the world. Moreover, with the rise of HIV/AIDS over the past two decades, there is now a significant population of immunocompromised individuals who are highly susceptible to TB and can potentially spread the disease like an uncontrollable wildfire. Major social upheavals during these years have also resulted in mass migration movements around the globe. Each of these factors has created the conditions the tubercle bacillus needs to thrive once again, inspiring the World Health Organization to classify tuberculosis as "a global health emergency."5 My fellow subway passengers that afternoon may have been worried about the off chance of meeting an anthrax spore. A few may have been contemplating the risk of a terrorist delivery of smallpox virus or even the highly unlikely importation of Ebola virus. I was, and am, far more concerned about contracting TB.

Few stories of tuberculosis demonstrate its unpredictability better than that of one of the immigrants I met in a professor's office near the New York-Presbyterian Hospital Tuberculosis Clinic. Alejandro, a fifty-year-old laborer who came to the United States illegally from Ecuador in 1999, was a relatively new patient at the clinic and had just been declared "noncontagious" after a four-week hospital stay.6 In Quito, he had been employed as a building contractor's assistant and "worked twelve or more hours a day, six to seven days a week, for over twenty-nine years." As with many immigrants before and since, economic insecurity was his major impetus for leaving Ecuador: "The price of food in Quito-the price of everything-is very high. We simply could not make it in my country. So I decided I had to go to America alone, whatever the cost, to bring in more money for my family."

In the late summer of 1999, Alejandro left his wife and three sons to begin a dangerous and illegal trip to the United States. The trip actually began months before when he procured the services of a coyote, a nefarious "travel agent" who specializes in smuggling human cargo across international borders. Alejandro met the coyote through some friends in Quito, although he noted that these "professionals" advertise in newspapers and are relatively easy to find. Alejandro's coyote was "a well-dressed, slick guy who promised a safe journey using his extensive network of contacts, the best means of travel, good food, everything." But the "travel package" came at a steep price: $7,000. This sum, several times more than Alejandro's annual income, required him to take out a mortgage on his family home. However, the financial transaction was not executed at a bank. The entire deal, even down to a payment plan that charged 5 percent interest per month, was completed between the two men on the street in front of Alejandro's house. Each month since he signed the paperwork for this deal, Alejandro has wired the coyote $250.

From Ecuador, without passport, visa, or luggage, Alejandro flew in a tiny propeller plane to the desert in southern Mexico. He then traveled across the interior toward Ciudad Juárez over a four-day period. For this leg of the journey, his means of transportation was the back of a dilapidated pickup truck squeezed in between forty-nine other illegal immigrants. To avoid the Mexican authorities, they drove a circuitous route along bumpy back roads. Alejandro rubbed his rear end as he recalled this part of his trip and remarked, "I can still feel every rock and pothole." Each night they slept outside and were sold a ration of food. A plate of rice and beans, Alejandro recalled, cost "about ten dollars."

Once the truck reached Ciudad Juárez, it was simply a matter of crossing the Rio Grande into El Paso. But the U.S. immigration workers stopped the truck as soon as it attempted to pass the border, and the briefest of inspections justified their suspicions. All fifty illegal immigrants-Ecuadorans, Nicaraguans, Panamanians, and a few Mexicans-were taken to jail. Following their instructions from the coyote, each immigrant told the Immigration and Naturalization Service (INS) officers they were seeking political asylum.

Alejandro sat in an El Paso jail for almost six weeks, but recalled it as a far better living arrangement than what he had endured during his travels. He was brought before the immigration court and required to post a $3,000 bail bond. Fortunately, he was able to contact some relatives who had long ago settled in New York, and they wired this princely sum to the authorities. The judge questioned Alejandro through an interpreter and allowed him to be released provided he return for a more definitive hearing at a later date. Naturally, Alejandro agreed to these terms and promptly gave the bailiff a fictional address at which to contact him. Soon after, he assumed a false name and purchased a bus ticket to New York. He had no papers, no legal identity, not even claim to his given name. He was an undocumented immigrant. His is hardly an exceptional tale. At present, while two-thirds of the illegal immigrants arrested along the Mexican and Canadian borders voluntarily return to their lands of origin, of those who remain, 90 percent never show up for their hearings, and little if any effort is made to find them.7

A few weeks after Alejandro arrived in New York City, he found a job at a delicatessen in the downtown financial district. Alejandro's physician told me later that about half of the illegal immigrants in New York work in the food services industry. To be sure, those with active tuberculosis do not pose the same immediate health risks to unsuspecting diners as "Typhoid Mary" Mallon, the cook who caused several Salmonella outbreaks in New York City during the early twentieth century.8 Nevertheless, the possibility that an illegal immigrant harboring a contagious disease with little or no access to health care is preparing your next egg salad sandwich, at the very least, should seriously curb your appetite.

At the deli, Alejandro worked fourteen hours a day, six days a week performing tasks such as cleaning up the tables, making sandwiches, and restocking the bountiful salad bar that nourished the harried stockbrokers, lawyers, and office workers who came in for a quick meal. He was paid about $500 a week, always in cash. After covering his own room and board and the coyote's monthly fee, whatever money he had left over each month Alejandro wired to his wife in Ecuador.

Despite these hardships Alejandro observed, "Everything was working out fine until this past summer." At that point, the tubercle bacilli he may have inhaled in Ecuador or even in the United States activated with a vengeance, causing intense sweating, fatigue, and difficulty standing upright. "At first, I blamed it on the hard work," Alejandro explained, "the long hours, the summer heat. But these problems would not go away. No matter how much rest I got on Sundays, I still felt terrible. Worse than I ever felt in my entire life. I had these headaches, terrible, it felt like someone was hitting me over the head with a brick."

Alejandro lived in a small two-room apartment with eight other Ecuadoran men, all illegal immigrants, on the Harlem side of Morningside Park, just a few blocks from Columbia University. They fashioned cardboard partitions between their beds to give some sense of privacy, but there was little to be had. Victor, a middle-aged man who slept in the bed next to Alejandro and worked with him at the delicatessen downtown, insisted that he see a doctor. One Monday morning, the two men skipped work and made a visit to a Spanish-speaking physician on West Ninety-sixth Street. Alejandro later complained: "He didn't ask me to take my shirt off. He didn't take any blood, get an X-ray, nothing." Instead, the physician stopped his inquiry after hearing the words "terrible headaches" and prescribed a new anti-inflammatory pain reliever named Vioxx. The pills did little for Alejandro's headaches, but their $70 price tag plus the doctor's $50 fee wreaked havoc on his carefully calibrated budget.
Howard Markel|Author Q&A

About Howard Markel

Howard Markel - When Germs Travel

Photo © Joyce Ravid

Howard Markel, M.D., Ph.D., is the George E. Wantz Distinguished Professor of the History of Medicine and director of the Center for the History of Medicine at the University of Michigan. His books include Quarantine! and When Germs Travel. His articles have appeared in The New York Times, The Journal of the American Medical Association, and The New England Journal of Medicine, and he is a frequent contributor to National Public Radio. Markel is a member of the Institute of Medicine of the National Academy of Sciences and lives in Ann Arbor, Michigan.

Author Q&A

A Conversation with Howard Markel

Q: Over the past century, so many new contagious diseases have reached epidemic proportions. What led you to investigate the six epidemics detailed in WHEN GERMS TRAVEL?
A: For almost twenty years, I have both practiced medicine and studied the history of medicine and public health. All of this work has forced me to conclude that, without question, the major health threats facing humankind today are contagious, epidemic diseases. This is because we live in a world of deadly germs that travel freely and widely. Given the remarkable pace of international transportation and the burgeoning rate of human migration around the globe, we are at serious risk for a return to the type of global pandemics that have not been seen in almost a century.

Q: But why look to history? Why not look to the future?
A: Over the past several decades doctors have been remarkably successful in identifying the microbial causes of specific infectious diseases, creating miraculous medicines, such as antibiotics, that can treat many of these scourges, and developing vaccines that prevent some contagious diseases before they ever have a chance to strike. Yet thereï¿*s a dangerous paradox to these successes in that the best public health programs are silent in nature. When the system is working well, few diseases break out and those that do are quickly contained. These very successes, however, lead us to become overconfident that germs have been conquered. But, of course, we never really conquer germs. We merely wrestle them to a draw. Or to put it another way, the complex dance between these living beings, humans and microbes, is eternal. What changes from era to era is which living being is actually leading in that dance. Since the advent of antibiotics during the 1950s, especially, human beings have appeared to be in control but over the past few decades the germs have evolved to outwit our best attempts to annihilate them.

But merely citing scary statistics of the incidence of disease is not enough to alert Americans about the global threat of contagion. All of usï¿*from doctors to patientsï¿*are better able to understand and relate to these dangers when hearing about epidemics as they affected the lives of real people. These stories of six epidemics that invaded the United States between 1900 and 2001 are driven by conflict, panic, contention, bravery, scientific discovery, brilliant detective work, and detail lives that were markedly altered because of a chance meeting with a deadly microscopic organism.

Q: Tell me some of the most interesting things you learned and report upon?
A: To begin with, there are far many more similarities in how Americans have responded to epidemics over the past one hundred years than differences. Most troubling, we have repeatedly searched for a scapegoat, either an individual or a social group that the majority of Americans have deemed to be ï¿*undesirableï¿*, to blame for a particular outbreak. Across time there have been many different candidates for this dubious distinction such as the urban poor, African-Americans, and, more recently with the AIDS epidemic, gay men. But one of the most consistent scapegoats for the importation of infection onto American soil over the past hundred and fifty years has been the immigrant. The nationalities of these immigrants have changed with each generation, from Chinese and East European Jews at the beginning of the twentieth century, to Haitians accused of importing AIDS and Rwandans thought to carry cholera germs at the centuryï¿*s close. At the same time, we Americans are quite adept at failing to ameliorate those conditions that give rise to many of these diseases in the first place. We also tend to forget that microbes are quite egalitarian in their mode of attack and are the least prejudiced of living beings.

Q: How are the epidemics of the early 20th century different from those we see today?
Specific epidemic diseases that frightened Americans of one era are hardly given a second thought in another. For example, trachoma, the dreaded eye infection that continues to rob more than 10 million people of their sight each year, was considered the number one imported health threat of the early 20th century. Indeed, the U.S. government invested millions of dollars in creating the U.S. Public Health Service and vast inspection factories such as the famed Ellis Island to insure that diseased immigrants did not enter the United States where they might harm unsuspecting American citizens. Similarly bubonic plague and cholera were among the most dreaded contagious diseases of the late 19th centuries, and with good reasonï¿*these microbes managed to kill millions of people as they traveled around the globe. Yet today, most of us consider these still active scourges to be relics most reliably found in a dusty, old medical textbook or a museum.

But what was most exciting for me to learn about and report on were the lives of the individuals who make up these stories of imported infection and their harrowing encounters with deadly and contagious diseases: a Chinese immigrant in San Franciscoï¿*s Chinatown in 1900 who was accused of spreading bubonic plague; an East European rabbi with trachoma who was detained at Ellis Island in 1917; a group of Mexican women who staged a riot at the Texas-Mexico border when they were erroneously accused of harboring typhus fever at the height of Pancho Villaï¿*s revolution; and more recently, Haitians who escaped death in their own country in the 1990s only to be handed a death sentence in the form of positive HIV tests and incarcerated on the U.S. Naval Base at Guantanamo, Cuba; Rwandan refugees living in Detroit during the late 1990s suspected of bringing cholera into the United States; and immigrants settling today in New York City with active tuberculosis.

Q: You discuss trachoma, bubonic plague, tuberculosis, AIDS, cholera, and typhus fever. What can you tell us about these diseases that we probably wouldnï¿*t otherwise know?
A: Ironically, most of my medical students donï¿*t know much about many of these diseases, so I suspect that all of us, regardless of our level of medical knowledge, have much to learn about some of the leading contagious killers of the past century. All of the microbes described in WHEN GERMS TRAVEL are remarkably different from one another, how they live, reproduce, and attack the body. Doctors like me are, of course, fascinated by the inner workings of disease and I had great fun developing engaging and exciting descriptions of these infections that I hope will enthrall and enlighten the reader.

Every infectious diseases described in the book has a wonderful history including how it altered and affected human society, what the modern study of microbiology and genetics can tell us about them today, and the remarkable men and women who tracked them down so that we could develop the miraculous medical armamentarium we continue to benefit from. Doctors like Louis Pasteur, Robert Koch, William Osler, or Selman Waksman may be vague or barely recognizable names to many 21st century readers. Yet once learning about these microbe huntersï¿* exciting exploits and their risky adventures in discovering the cause of killers like anthrax, cholera, TB, AIDS, as well as the invention of antibiotics, one cannot help but be awed by their collective genius. All of these medical heroes made the world a much safer and healthier place.

Q: One of the most frightening stories in your book comes up in the chapter on tuberculosis: a young Korean woman spreads the disease to 29 of her fellow airline passengers as she travels from Seoul to Baltimore simply by coughing during the flight. If tuberculosisï¿*s threat is so widespread and contagious, why arenï¿*t we doing more to contain it?
A: Tuberculosis is unquestionably ï¿*Public Health Enemy Number Oneï¿* in the world today. Of the worldï¿*s 6 billion people, more than a third, 2.1 billion, are infected with the tuberculosis germ. Each year, 15 million of these people go on to develop the active form of the disease and 8 million die of TB. In the time between first contracting the TB germ to effective treatment or death from it, a TB patient will infect 20 other people. And, 1 out of every ten cases of TB today is resistant to the antibiotics we have to treat the disease making many patients as incurable as they were a half a century ago.

But thereï¿*s even more bad news. TB is readily transmitted from person to person by coughing, speaking, and plain ordinary breathing. Indeed, it is extremely easy to catch tuberculosis. All you have to do is spend significant time, eight hours or more, breathing in the same room or airplane cabin with someone who is ill with itï¿*like the story in the book. Worse, every infectious person who can spread TB is not always recognizably illï¿*there are hundreds of thousandsï¿*if not millions-- of TB silent travelers all over the globe spreading the infection to others every minute of the day. Perhaps now you can understand why the threat of tuberculosis keeps me up at night.

Sadly, because TB is so familiar, such ï¿*old newsï¿* to so many Americans, it does not garner the respect it deserves. Many believe it is a completely conquered disease; others never even give TB a thought. In reality, TB is making a comeback of mammoth proportions around the world.

Q: SARS took the world by surprise last spring. Are there other infectious diseases we should be aware of?
A: First of all, we can also take heart in some of the positive aspects of last yearï¿*s SARS epidemic. While it certainly created a worldwide panic and economic hardship to those areas hardest hit, modern technology and medical science enabled us to figure out its exact cause, mode of travel, and the ways to stem the tide of that epidemic in a period of eight daysï¿*an absolute record time in the history of humankind.

We must also be aware of re-emerging infectionsï¿*scourges we thought were once conquered such as malaria, cholera, diphtheria, measles, diarrheal diseases, and, of course, the greatest threat of all, tuberculosis. In the past hour alone, more than 1,500 people around the world died of these maladiesï¿*and most of them are entirely preventable! A critical aspect of this awareness is in recognizing that in the 21st century, the health of a remote village in Rwanda or China has serious implications for those of us living in New York, Chicago, or Seattle. Simply put, germs travel and we must constantly be on guard against them and ready to take action when they do spread or get out of control.

Q: What about AIDS? Why is it less on our radar screens now than in the past?
A: Thereï¿*s no question that AIDS is still an international threat to the publicï¿*s health. Indeed, last November the U.S. Central Intelligence Agency classified AIDS as one of the most serious national security risks to the United States as well as to Russia, India, China, and Africaï¿*where most of the new cases are appearing. Already, more than 45 million people are infected with HIV and by the year 2020, another 65 million will be HIV positive. In the last hour alone, more than 300 people died of AIDS, a death toll that increases with each passing day.

But because we have become used to the threat of AIDS, many of us refuse to pay it the attention and respect it deserves. Like tuberculosis, AIDS is yesterdayï¿*s news. Ironically, modern medicine has transformed both TB and AIDS from rapid killers into long-term, chronic diseasesï¿*illnesses that require months to years of medications. The history of epidemics demonstrates time and again that we all tend to be far more excited, if not outright inspired to action, by those infections that kill quickly and spectacularly, even when the number of deaths is markedly smaller when compared to the more familiar scourges that kill millions year in and year out. Compare, for example, the attention we paid to SARS last year, which tragically ended the lives of 7,000 people, to AIDS and TB which together killed more than 12 million people in 2003.
Q: What can we learn from these six epidemics? And what international steps should be taken to prevent the spread of future epidemics?
A: All of these stories demonstrate the absolute necessity of a strong internationally cooperative public health system. I hope that the lessons of the six epidemics described in WHEN GERMS TRAVEL help readers realize that the spread of deadly epidemics is real, ever present, and demands nothing less than constant global surveillance, intervention and preventionï¿*including adequate supplies of medicines and vaccines--backed by a steady stream of human and financial resources to do the job.

Today, doctors have far less time to react to germs that travel than in years past. As SARS demonstrated last spring, infectious diseases today race abroad via jetliners. As such, these dangerous microbes often arrive while still incubating in the people who may carry them but who do not yet demonstrate obvious signs of that illness. The catch is that while the germ has not yet actually declared itself, it has more than ample opportunity to spread to othersï¿*making the global village a far smaller and infectious place than it has ever been in human history.

Q: What can we do in the future to contain contagious disease?
The exciting news is that we can do so much to contain future waves of the major infectious diseases that stalk the planet. The United Nations recently estimated that if everyone living in a wealthy nation contributed one-tenth of one percent of their gross national product to a global public health fund, we could save 21,000 lives a day before the end of the decade. Think about it, for an annual investment of about 50 billion dollarsï¿*or on an individual basis, the cost of one movie ticket and a soft drink a year and similar contributions from the wealthy corporations of the world--we could provide the medicines to treat most of those afflicted with AIDS, tuberculosis, and malaria, and, with safe, effective vaccines, to completely prevent many other contagious diseases, such as influenza, measles, and diphtheria. If the humanitarian impulse is not enough to fund such an endeavor, we can take comfort in the fact that the lives saved from such an effort would create an annual savings of more than $360 billion in lost wages and productivity. Compare that return on investment to what we get for the annual expenditure of $800 billion for weapons and armed forces that the nations of the world pay out each year.

Paradoxically, the success we enjoyed during the 20th century in taming epidemics has inspired in many a false confidence that we have conquered pathogenic microbes, leading us to under fund or completely ignore public health programs designed to prevent epidemics from reoccurring. This mindset is beyond foolhardyï¿*it is downright dangerous.

Undoubtedly, the greatest public health achievement of the 21st century will be the universal acceptance of the fact that we must always be on guard against epidemics and, because germs travel so easily and quickly, we must actively improve the public health of all the worldï¿*s citizens. The central message of my book is that the history of epidemics in America and around the world teaches us that while we will never completely conquer these deadly germs, we stand a much better chance of wrestling them to a draw if we act before rather than after the fact of an outbreak.

From the Hardcover edition.



“Even if threats like Asian flu and bioterrorism don’t keep you up at night, this 2004 chronicle of epidemics in America is worth reading purely for the historical dramas it relates.” —Jonathan Cohn, The New Republic“Markel, a medical historian at the University of Michigan, vividly describes six infectious outbreaks in the United States—tuberculosis, bubonic plague, trachoma, typhus, cholera and AIDS—that became associated with immigrants and triggered quarantines and deportations.” —The New York Times Book Review“Informative and important. . . . Thoroughly researched, well argued, and replete with insightful, nuanced interpretations.” —St. Louis Post-Dispatch“Compelling. . . . Markel’s accounts are powerful and his documentation extensive. . . . Everyone who considers the United States a nation of civilized people should read this book.” —Wilson Quarterly“Markel is . . . an astute observer of the fierce historical battles between people and germs, and he reminds us that the war goes on and on. . . . Well-written and approachable.” —The Ann Arbor News“Markel writes beautifully, and his perspective as both a trained historian and a dedicated physician make him a writer like no other.” —Abraham Verghese“A critically important book for this historical moment. . . . A clarion call for the public (and the government) to recognize both the importance and the precariousness of public health as we enter the twenty-first century.” —Health Affairs“Deft, interesting and informative.” —The Roanoke Times“Dr. Markel is an epic historian, a wise scientist, and an elegant prose stylist. . . . Written with humor, grace, insight, and warmth, When Germs Travel is a discerning portrait of illness, a comment on the immigrant experiences of the past and present, and a reflection on what it means to be a doctor in a society ruled by fear of contagion.” —Andrew Solomon, author of The Noonday Demon
“Markel writes with great attention to the human side of the story. . . . A powerful, sweeping story about immigration, poverty, public health, scientific breakthroughs and medical failures.” —Chicago Free Press“Markel proves just how compelling medical history can be in these lucid, thought-provoking accounts of the complex intersection of immigration policy and public health.”—Andrea Barrett, author of Ship Fever“Highly readable. . . . Dramatic and graphic.” —Tucson Citizen
“A timely book. Markel, a medical historian and himself a physician, knows that the so-called general reader needs to be guided through the maze of technicalities, and he does the guiding in a text as readable as it is reliable. It reads like a thriller.” —Peter Gay, Sterling Professor of History Emeritus, Yale University
“Solid information on a serious subject, delivered with great assurance and style.” —Kirkus Reviews

“Dr. Markel . . . is both passionate and compassionate about his subject and conveys this devotion in clear, precise, gentle prose that is in the tradition of such great doctor-writers as A. J. Cronin, Somerset Maugham, Sherwin Nuland, Lewis Thomas, and William Carlos Williams—doctors for whom the patient was the important part of the story most necessary for breaking the reader’s heart.” —Larry Kramer, author of Reports from the Holocaust“A crisp, brisk and matter-of-fact narrative that can be more chilling than anything Stephen King has ever committed to paper. . . .This important cautionary tale proves infectiously readable.” —Flint Journal
“Informative and important. . . . For each epidemic, Markel weaves a vivid description of the natural history of the disease with an account of how the disease entered the United States, spread and ultimately faded away. Markel portrays these events through engrossing stories of individual victims. . . . Enthralling. His ability to make medicine accessible and understandable to lay readers is remarkable.” —St. Louis Post-Dispatch“In this very readable book, Markel chronicles yet another way in which this fear has played a critical role in the history of the U.S.—a nation built from collections of others. In addition to telling a fascinating historical story . . . this book reminds us all that prejudice, no less than science, often drives health policy.” —Jerusalem Post

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A personal message: