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Today, plague is rare in the United States, but it has been known to occur in parts of California, Arizona, Colorado, and New Mexico

in Europe, massive plague epidemics killed millions of people. Plague can still be found in Africa, Asia, and South America.

someone with pneumonic plague coughs, tiny droplets carrying the bacteria move through the air. Anyone who breathes in these particles may catch the disease. An epidemic may be started this way.

Bubonic plague -- an infection of the lymph nodes Pneumonic plague -- an infection of the lungs Septicemic plague -- an infection of the blood

Bubonic plague symptoms appear suddenly, usually after 2 - 5 days of exposure to the bacteria. Symptoms include: Chills Fever General ill feeling (malaise) Headache Muscle pain Seizures Smooth, painful lymph gland swelling called a bubo Commonly found in the groin, but may occur in the armpits or neck, most often at the site of the infection (bite or scratch) Pain may occur in the area before the swelling appears

Pneumonic plague symptoms appear suddenly, typically 2 - 3 days after exposure. They include: Cough Difficulty breathing Fever Frothy, bloody sputum Pain in the chest when you breathe deeply Severe cough Septicemic plague may cause death even before its symptoms occur. Symptoms can include: Abdominal pain Bleeding due to blood clotting problems Diarrhea Fever Nausea Vomiting

Tests that may be done include:

Blood culture Culture of lymph node aspirate (fluid taken from an affected lymph node or bubo) Sputum culture

People with the plague need immediate treatment. If treatment is not received within 24 hours of when the first symptoms occur, death may occur.

Antibiotics such as streptomycin, gentamicin, doxycycline, or ciprofloxacin are used to treat plague

Oxygen, intravenous fluids, and respiratory support usually are also needed.

Patients with pneumonic plague should be strictly isolated from caregivers and other patients. People who have had contact with anyone infected by pneumonic plague should be watched carefully and given antibiotics as a preventive measure.

Without treatment, about 50% of people with bubonic plague die. Almost all people with pneumonic plague die if not treated. Treatment reduces the death rate to 50%

Rat control and watching for the disease in the wild rodent population are the main measures used to control the risk of epidemics. A vaccination is available for high-risk workers, but its effectiveness is not clearly established

Typhoid Mary, for intentionally spreading the deadly illness

rasp all of it yet.The Department of Health knew what caused typhoid, but dealin

scientists had developed a sophisticated understanding of microbial diseases and how they spread -- even if everyone in the lay public didn't quite

In turn-of-the-century New York City, typhoid was a growing problem. The Department of Health had a lot on its plate; in addition to typhoid, it was trying to quell out­breaks of smallpox, tuberculosis, diphtheria and whooping cough that were sweeping through the area [source: NOVA]. Luckily,

g with the spread of the disease was another question altogether. It's a question that plagues us to this day. It's no longer considered humane to simply cast contagious disease victims out of society and into the wilderness to fend for themselves. What exactly to do with them remains controversial. Authorities must walk the line between keeping their societies safe from debilitating illness and infringing on the victims' personal rights. This controversy reached a fever pitch in early 20th-century New York when it came to one individual.It might surprise you to learn that this fervor revolved around someone who was actually immune to typhoid. Though it's uncommon, some people are naturally immune to the illness, meaning they can carry the parasite and never suffer from a single symptom. Nevertheless, these people can just as easily spread the disease to others. This was the case for one Mary Mallon, aka Typhoid Mary. She was in the wrong place at the wrong time as well as in the worst possible occupation for a carrier of typhoid: She was a cook.

Painful diarrhea, high fever, nasty red rashes and sleeplessness typically characterize the illness. Left untreated, typhoid can result in death.

The effect of the influenza epidemic was so severe that the average life span in the US was depressed by 10 years. The influenza virus had a profound virulence, with a mortality rate at 2.5% compared to the previous influenza epidemics, which were less than 0.1%. The death rate for 15 to 34-year-olds of influenza and pneumonia were 20 times higher in 1918 than in previous years (Taubenberger). People were struck with illness on the street and died rapid deaths. One anectode shared of 1918 was of four women playing bridge together late into the night. Overnight, three of the women died from influenza (Hoagg). Others told stories of people on their way to work suddenly developing the flu and dying within hours (Henig). One physician writes that patients with seemingly ordinary influenza would rapidly "develop the most viscous type of pneumonia that has ever been seen" and later when cyanosis appeared in the patients, "it is simply a struggle for air until they suffocate," (Grist, 1979). Another physician recalls that the influenza patients "died struggling to clear their airways of a blood-tinged froth that sometimes gushed from their nose and mouth," (Starr, 1976). The physicians of the time were helpless against this powerful agent of influenza. In 1918 children would skip rope to the rhyme (Crawford):

The origins of this influenza variant is not precisely known. It is thought to have originated in China in a rare genetic shift of the influenza virus. The recombination of its surface proteins created a virus novel to almost everyone and a loss of herd immunity. Recently the virus has been reconstructed from the tissue of a dead soldier and is now being genetically characterized. The name of Spanish Flu came from the early affliction and large mortalities in Spain (BMJ,10/19/1918) where it allegedly killed 8 million in May (BMJ, 7/13/1918). However, a first wave of influenza appeared early in the spring of 1918 in Kansas and in military camps throughout the US. Few noticed the epidemic in the midst of the war. Wilson had just given his 14 point address. There was virtually no response or acknowledgment to the epidemics in March and April in the military camps. It was unfortunate that no steps were taken to prepare for the usual recrudescence of the virulent influenza strain in the winter. The lack of action was later criticized when the epidemic could not be ignored in the winter of 1918 (BMJ, 1918). These first epidemics at training camps were a sign of what was coming in greater magnitude in the fall and winter of 1918 to the entire world.

The effect of the influenza epidemic was so severe that the average life span in the US was depressed by 10 years.

"The 1918 has gone: a year momentous as the termination of the most cruel war in the annals of the human race; a year which marked, the end at least for a time, of man's destruction of man; unfortunately a year in which developed a most fatal infectious disease causing the death of hundreds of thousands of human beings. Medical science for four and one-half years devoted itself to putting men on the firing line and keeping them there. Now it must turn with its whole might to combating the greatest enemy of all--infectious disease," (12/28/1918).

riers, along trade routes and shipping lines. Outbreaks swept through North America, Europe, Asia, Africa, Brazil and the South Pacific (Taubenberger). In India the mortality rate was extremely high at around 50 deaths from influenza per 1,000 people (Brown).

With the military patients coming home from the war with battle wounds and mustard gas burns, hospital facilities and staff were taxed to the limit. This created a shortage of physicians, especially in the civilian sector as many had been lost for service with the military. Since the medical practitioners were away with the troops, only the medical students were left to care for the sick. Third and forth year classes were closed and the students assigned jobs as interns or nurses (Starr,1976). One article noted that "depletion has been carried to such an extent that the practitioners are brought very near the breaking point," (BMJ, 11/2/1918). The shortage was further confounded by the added loss of physicians to the epidemic. In the U.S., the Red Cross had to recruit more volunteers to contribute to the new cause at home of fighting the influenza epidemic. To respond with the fullest utilization of nurses, volunteers and medical supplies, the Red Cross created a National Committee on Influenza. It was involved in both military and civilian sectors to mobilize all forces to fight Spanish influenza (Crosby, 1989). In some areas of the US, the nursing shortage was so acute that the Red Cross had to ask local businesses to allow workers to have the day off if they volunteer in the hospitals at night (Deseret News). Emergency hospitals were created to take in the patients from the US and those arriving sick from overseas.

DefinitionYellow fever is a disease carried by female mosquitoes. The species of mosquito that carry yellow fever are native to sub-Saharan Africa and South America, but can also be found in other areas. Although it may be rare in developed countries, yellow fever is endemic in impoverished areas where people cannot afford to get vaccinated.

Prevention Vaccination is the best way to prevent yellow fever. The yellow fever vaccine is recommended for people aged 9 months to 59 years who are traveling to or living in areas where the disease is present. Your doctor will help decide if the vaccine is right for you.

Mallon, now extremely suspicious of these health officials, refused to listen to Baker, Baker returned with the aid of five police officers and an ambulance. Mallon was prepared this time. Baker describes the scene:

Mary was on the lookout and peered out, a long kitchen fork in her hand like a rapier. As she lunged at me with the fork, I stepped back, recoiled on the policeman and so confused matters that, by the time we got through the door, Mary had disappeared. 'Disappear' is too matter-of-fact a word; she had completely vanished.3

footprints were spotted leading from the house to a chair placed next to a fence. Over the fence was a neighbor's property. They spent five hours searching both properties, until, finally, they found "a tiny scrap of blue calico caught in the door of the areaway closet under the high outside stairway leading to the front door."4

After a trial and then a short run from health officials, Typhoid Mary was recaptured and forced to live in relative seclusion upon North Brother Island off New York. Who was Mary Mallon and how did she spread typhoid fever? An Investigation

For the summer of 1906, New York banker Charles Henry Warren wanted to take his family on vacation. They rented a summer home from George Thompson and his wife in Oyster Bay, Long Island. Also for the summer, the Warrens hired Marry Mallon to be their cook.

On August 27, one of the Warren's daughters became ill with typhoid fever. Soon, Mrs. Warren and two maids became ill; followed by the gardener and another Warren daughter. In total, six of the eleven people in the house came down with typhoid. Since the common way typhoid spread was through water or food sources, the owners of the home feared they would not be able to rent the property again without first discovering the source of the outbreak. The Thompsons first hired investigators to find the cause, but they were unsuccessful. Then the Thompsons hired George Soper, a civil engineer with experience in typhoid fever outbreaks. It was Soper who believed the recently hired cook, Mary Mallon, was the cause. Mallon had left the Warren's approximately three weeks after the outbreak. Soper began to research her employment history for more clues. Mary Mallon was born on September 23, 1869 in Cookstown, Ireland. According to what she told friends, Mallon emigrated to America around the age of 15. Like most Irish immigrant women, Mallon found a job as a domestic servant. Finding she had a talent for cooking, Mallon became a cook, which paid better wages than many other domestic service positions. Soper was able to trace Mallon's employment history back to 1

900. He found that typhoid outbreaks had followed Mallon from job to job. From 1900 to 1907, Soper found that Mallon had worked at seven jobs in which 22 people had become ill, including one young girl who died, with typhoid fever shortly after Mallon had come to work for them.1 Soper was satisfied that this was much more than a coincidence; yet, he needed stool and blood samples from Mallon to scientifically prove she was the carrier.

To be sure, Mary Mallon was not entirely blameless when she knowingly returned to cooking in 1915, but the blame must be more broadly shared. Much of what Mallon did can be explained by events greater than herself and beyond her control.

the New York City Health Commissioner who had released her in 1910

, helped her find a job in a laundry, it did not provide the wages or job satisfaction to which she had previously become accustomed. Nor did it provide the social amenities, as limited as they were, of domestic work in the homes of New York's upper class.

Lederle's words of obligation to help her in 1910

did not provide her

long-term gainful employment.

precipitously locked Mallon up, succeed in convincing Mallon that her danger to the health of people for whom she cooked was real and lifelong. The medical arguments that carried weight among the elite at the time and have become more broadly convincing since did not resonate with her. There was no welfare system to support her. There was no viable "safety net," practical or intellectual, for an unemployed middle-aged Irish immigrant single woman.

An old file card detailing results from tests on stool specimens from Mary Mallon gives a capsule history of her capture and quarantine. Enlarge

Hard choices

Health officials chose not to deal with their first identified healthy carrier in a flexible way.

Part of the New York American article of June 20, 1909, which first identified Mary Mallon as "Typhoid Mary" Enlarge

Proper treatment

The Most Dangerous Woman in America.

Some four million men were mobilized in the U.S. Armed Forces. Training camps and stations were often overcrowded. Soldiers and sailors routinely were packed on to passenger trains and sent to training stations and bases around the nation

When influenza struck the United States in the fall of 1918, it almost universally appeared in military populations before hitting civilian communities. Medical officers attempted to contain the epidemic through a host of measures, including nasal-pharyngeal sprays for all troops, quarantine of new arrivals, and isolation of cases in camp hospitals or special emergency

As the influenza epidemic raged, scientists and physicians struggled to isolate the causative microbe and to develop an effective vaccine against it.

Quacks and naysayers, on the other hand, advocated a host of alternatives such as raw onions rubbed on the chest, creosote baths, and the consumption of large quantities of brown sugar. Some—including several city health officers—claimed that a clean heart, clean bowels, or warm feet were all that was needed to stave off influenza.

Health officers, mayors, and city councils ordered theaters, movie houses, dance halls, saloons, schools, churches, and other places of public gathering to close for the duration of the epidemic.

Local courts, on the other hand, had more flexibility in how they met the crisis

Seattle saw a drastic drop-off in the number of marriage license applications during the epidemic (although, interestingly, the number of divorce filings increased).5

World War I did not just affect soldiers, sailors, and Marines. On the home front, civilians were expected to contribute to the war effort as well by self-rationing food, fabric, gasoline, and other goods, and by purchasing Liberty bonds.

people in close proximity to one another. In the East, where the deadly fall wave

American Red Cross, the Visiting Nurse Association, the Blue Circle Nurses, the Public Health Nurses, and others played a vital role during the influenza epidemic, providing nursing care to the ill, staffing emergency hospitals, organizing volunteers, coordinating relief efforts, assembling gauze face masks, and operating ambulances. Communities across the nation were overwhelmed by the

magnitude of the crisis,

In the three decades after 1890, nearly 24 million immigrants arrived on the shores of the United States

The 1918 influenza pandemic took a horrible toll of death and destruction in the United States

there are regular cases of bubonic plague that spring up every year in the American southwest

Occasionally, they lead to deaths

they lead to people scratching their heads as they read the newspaper and wondering aloud, "How do we still have the plague?

San Francisco was both a local hub of industry and a port to ships coming in from the far east. Each of those ships had to pass a health inspection before they docked, of course, but both the passengers and the local businesses pressured the health inspectors to get it out of the way as quickly as possible

They did this even after cases of plague, and mini-epidemics, broke out in China, and then in Hawaii.

WHO fact sheet Disease Outbreak News: yellow fever International travel and health: yellow fever International Health Regulations (IHR)

    George Thompson, the owner of the house, was particularly worried, concerned that no well-to-do New Yorkers would be of a mind to rent his home the following season if it was associated with disease. The house was very large, and expensive to run. Thompson himself, though the owner of four other homes, could not afford to live there. If the house lay vacant, it would mean disaster. Desperate, he called in experts to track down the source of the contagion, hoping it came from outside the property and eager for someone to prove it.     Drinking water was analyzed. The single indoor toilet, the cesspool, manure pit, and outhouse were all examined and ultimately rejected as the possible source of infection.

    Dairy products were inspected.     An old woman who lived on the beach was considered a likely suspect. She had offered the family clams for sale, and these were scrutinized minutely, but no one else in th

e town who had eaten shellfish from the same source had fallen ill.

    Thompson, unsatisfied with the inconclusive results from local health authorities on the scene and from his hired experts, reached out to friends in New York City, looking for someone, anyone, to help him with his embarrassing problem.     Salvation didn't exactly ride in on a white horse. Nor was Dr. George Soper hero material exactly. Dr. Soper was not even in fact a medical doctor. He was a sanitary engineer — as one newspaper described him: `a doctor to sick cities.'     Called into the fray, he took the train out to Oyster Bay from the city and set immediately to work. After reviewing the findings of the first medical men on the scene, as well as those of earlier experts who had scrutinized the drinking water, trash and sewage, he began questioning members of the household, inquiring about visitors, ultimately receiving a comprehensive list going back an impressive ten years. To the best of his ability, Soper examined the medical histories of each of these individuals, eventually ruling all of them out as possible sources.

    Soper now uncovered `other episodes', as he called them. Provocatively, there was a two-year period for which there were no records available at all for Ms. Mallon's employment — the period between the Gilsey family incident and Mary's arrival in Oyster Bay.     The two-year blank was tantalizing to Soper. Where had Mary been? Who had she been cooking for? She must have been cooking somewhere ... The sanitary engineer's mind teemed with disturbing images. He no doubt pictured the cook stirring soup in some unknown and very busy cellar kitchen, barehanded, unknowing, infecting untold multitudes of solid citizens with potentially deadly bacilli.     Dr. Soper's breathless, self-serving, yet ultimately unreliable accounts to newspapers give a sense of how excited he was, how exhilarated by the thrill of the chase and the tantalizing prospect of being onto something really important. At first he had anticipated a case that might last only a few weeks — a little sea air, a few bowls of steamers, some resolution, and back to the city — but now he found himself further drawn into a quest which had already occupied him for a full four months. The Warrens were long gone — back home with the other summer renters. The weather had turned colder, the house now stood empty.

    He went over the facts of the case as they had presented themselves to him. Here he had an unexplained outbreak of typhoid in an area where no typhoid of any kind had been previously. The home was immaculate, clean from top to bottom. All other possible sources of infection had been examined and ruled out. The only new element introduced into the household had been a cook. The cook handled food, which all the afflicted members of the household had eaten. The disease broke out, and the cook was now gone. Had she left under different circumstances, say, the disappearance of a diamond necklace, the cops — or any investigator — would have been looking very hard in her direction.     Soper got a description of the suspect: a woman of about forty, tall, with a buxom build, blond hair, blue eyes, and a firm mouth and jaw. It was remarked that she was `a pretty good cook', though she was observed by some interviewees in retrospect as bein

`not particularly clean' in her work habits and `difficult to talk to'.     Writing later, Soper describes what he did next:

    This was frustrating. Things usually went pretty quickly in cases like this. Feces in the water supply, contaminated milk, a sickly visitor, and case closed. Not so at the Thompson house. Soper began to `walk the cat backward' in search of an answer.     Typhoid's incubation period was known to be ten to fourteen days long, so he focused on a time on or before August 20. Soper was intrigued by the news that on the fourth of the month, the Warrens had seen fit to change cooks. More significantly, the new cook, a Mary Mallon, was now missing, having left without notice or explanation some three weeks after the sickness began.     A missing cook! It was the kind of lead that criminal investigators find almost too easy, too good to be true; evidence of a kind that prosecutors like to present to jurors as indicating `guilty knowledge', the kind of red flag that Miss Marple or Hercule Poirot would disregard automatically as being just too obvious. Look at it: A murder or some other felony is committed in a household or place of business, and someone who used to be there is suddenly no longer there. It doesn't take an investigative mastermind to deduce who to go looking for first. It was circumstantial evidence of the most provocative kind, and Soper was well acquainted with the old saw about circumstantial evidence: `It's like finding a goldfish in your milk. It doesn't prove anything — but it's mighty suspicious'.

    Carriers were a very hot concept in the new world of epidemiology, a theory unproven in the United States. In Germany, however, the respected bacteriologist Dr. Robert Koch had recently investigated repeated outbreaks of typhoid in a Strasbourg bakeshop. The bakery was clean. The water supply was uncorrupted. Yet well-heeled customers were getting sick. Dr. Koch questioned the proprietor and found that she had, years earlier, contracted typhoid, but had survived the experience and was now, seemingly, fully recovered. After testing her, Koch found that even though she was devoid of symptoms and to all outward appearances a healthy person capable of working and going about her tasks like everyone else, she was in fact still teeming with typhoid germs, exuding them through her bowel movements and spreading them with improperly cleaned hands. This was a revolutionary discovery, and news of it had found its way to New York, where it was discussed with interest. Soper had read the transcript of a speech Koch had given on the subject a couple of years previous.     Dr. Soper had learned of seemingly clean and affluent homes in Mary Mallon's past being struck with typhoid after her employment. Now he was confronted with similar circumstances in yet another place she had worked. Given that no human carrier such as Koch's bakery proprietor had ever been identified in America, Soper was suddenly very, very interested in getting his hands on the mysterious Mary Mallon.

    That she was evidently not interested in being found only piqued the good doctor's interest to even greater pitch:

    At this point, Soper already seems to have formed in his mind a picture of Mary as some kind of Moriarty-esque nemesis, an elusive and crafty adversary with the answer to all his questions, but always just out of reach.     He wanted her badly. His day-to-day work, by this time, had become closer to a detective's than a microbe-hunter's, interviewing witnesses, poring over records. He felt good. He was going to make his bones with this case. He foresaw himself as the poster boy for epidemiologists and health professionals, an honored and much-sought-after speaker at all the medical societies, a hero to the afflicted, a newspaper personality, idol to generations of aspiring sanitary engineers.     Furthermore, he knew that his work was important. Typhoid was lethal and, especially in 1906 and 1907, no joke.

    These were boom times. It was a new century and a new world that Soper lived in. The 1900 Chicago World's Fair had once and for all convinced Americans that they lived in a great country, a major world power, on a par — at least — with the European monarchies. Any inferiority complex New Yorkers and Americans might once have felt was rapidly disappearing in the light of an increasingly powerful, worldwide naval presence, a national construction explosion, the emergence of a newly affluent and pleasure-seeking middle class, the recent developments of subway systems, mass-produced automobiles, a tunnel under the Hudson River, new entertainments, libraries, an exuberantly sensationalistic press, and the warm glow of having recently drubbed the Spanish in Cuba and the Philippines. Great strides had been made in the fighting of disease and the word `epidemic' was now an embarrassment to a city. An earlier epidemic of typhoid and cholera had had New York and Philadelphia pointing fingers at one another, each claiming the other was responsible for the outbreak, both mortified that something so closely associated with the squalor of the old world would be blamed on their fair metropolis.     Soper's description of an earlier experience with a typhoid epidemic gives a flavor of what a man in his position saw as his responsibility, of what he perceived himself to be up against:

These were the stakes as Soper saw them. Confusion, suspicion, contagion, neighbor pitted against neighbor, panic in the streets, and ultimately, chaos and death.     Epidemics — especially unexplained ones — tended to bring out the worst in people, and the `carrier' theory, however fearful its implications, was far preferable to some of the alternatives. In the past citizens thought to be contagious — particularly if they were members of the minority or underclass — had hardly been taken to the bosom of their communities. Instead the usual outcome was for mob rule to win out. It was not unheard of for those thought to be infected to be run out of town on a rail or set adrift in the Long Island Sound — often at the point of a gun — or worse still. As Soper saw it, he needed a quick and tidy solution to the Oyster Bay problem.     Looking at pictures of Soper — a serious, narrow-faced, whippetlike man with a neat mustache and a receding hairline — one gets the impression of not so much the dogged detective he might have liked to see himself as, but of a timid, fastidious scientist, a man ensconced in reasoned practice and methodology. That he might have been racist, sexist, and far too influenced by the prejudices of his class — as has been suggested by revisionist accounts — a flawed, ambitious fellow who looked for the first likely Irish woman he could clap the manacles on — does not present itself through photography. Nor do we get much of that from his work later in life: tomes with titles such as: The Air and Ventilation of Subways (1908), Modern Methods of Street Cleaning

(1909), Further Studies of European Methods of Street Cleaning and Waste Disposal With Suggestions (1930), and of course, what proved his masterwork, the story for which he became best known, the pamphlet with a title like a Victorian detective story's The Curious Case of Typhoid Mary (1939).     George Soper looks from his photographs not to be a nice guy. He looks like someone who was bullied in high school, a nerd, a geek, an apple-polishing dirt-wonk with an unseemly interest in filth and how to make it go away.     It was not for a good many more months, not until March of 1907, that Soper finally came face to face with Mary Mallon. It was then that reports reached him that a family on Park Avenue in New York City had been stricken with typhoid. Two cases had initially been reported. A maid was ill, and a daughter of the people who owned the house, a beautiful young woman in her twenties, was lying on her deathbed. The family were reportedly beside themselves with grief. The girl died two days later, and soon the nurse who had attended her became str

icken as well.     The details of the case as they reached Soper were indeed tragic, another example of bad things happening to people to whom bad things are not supposed to happen; but what particularly excited Soper, got that Sherlock Holmes mojo working again, was the news that there was a new cook fitting the description of Mary Mallon still employed by the stricken family.

    The cook in question, and indeed it was Mary Mallon, did not quite share the good doctor's enthusiasm. She showed true displeasure when Soper, who rushed over to the Park Avenue address immediately upon receiving the news, suddenly showed up at her job, accusing her in no uncertain terms of causing the typhoid which right then was draining the life from one member of her employer's family.

    To his dismay, Mary did not see Soper as the answer to some long-troubling question about the series of odd and unpleasant coincidences that had long followed her. He stood an accuser, and she reacted thus, and her reaction seems to have come as a complete surprise to him.     Here, at this first meeting between pursuer and pursued, is where things began to go terribly wrong — at least for Mary Mallon and any future she might have had. What was said here, and how it was said, would set the tone for everything that happened after.