by The Pandemic Century- One Hundred Years of Panic, Hysteria
Meyer also worried about the way that rapid economic and industrial change was disrupting the balance between humans and microbes. However, in the case of psittacosis he placed the blame squarely on bird breeders and their stubborn insistence that psittacosis did not pose a threat, even as the disease claimed the lives of pet owners and medical researchers in Baltimore and Washington. Perhaps the most important factor of all, however, had been the popularity of lovebirds with American consumers and the lucrative interstate trade that saw itinerant peddlers going door-to-door offering parakeets to widows and housewives. In 1930, the idea that these cute American-bred birds might be the avian equivalent of Trojan horses was too disturbing to contemplate. Far easier to blame feathered green immigrants from the southern hemisphere.
* McCoy first isolated the bacterium of tularemia in 1911 while examining squirrels for plague lesions in Tulare County, California. Transmitted by ticks, mites, and lice, tularemia is endemic to every state in the US, the principal reservoirs being wild rabbits and deer. In humans, the tick or deer fly bites can result in ulceration and swelling of the lymph glands; hence its confusion with plague.
† In nonpsittacine birds, the infection is known as ornithosis.
‡ The ease with which people contracted psittacosis in the presence of parrots was seen as further evidence that the infective agent must be an intestinal parasite, even though in many cases patients had not touched sick birds or handled their fecal matter but had merely been in the same room as them.
§ This was an important clue to the natural history of the disease, one that helped explain why wild birds were not continually dropping dead of psittacosis and epizootics were rare. However, the significance of the finding would only become apparent to researchers in the mid-1930s. See discussion below.
¶ It also appears to have been motivated by the 1928–1929 influenza epidemic, the worst flu outbreak since the 1918 pandemic, and chemists’ desire to apply their knowledge to medical problems. In 1948, the institute’s name was pluralized to National Institutes of Health.
CHAPTER IV
THE “PHILLY KILLER”
“The outbreak . . . has presented a number of unusual and
complex features. . . . It has run counter to our expectations
that contemporary science is infallible and can solve all
the problems that we confront.”
—DAVID J. SENCER, director, CDC,
Atlanta, November 24, 1976
At the junction of Walnut Street and South Broad Street—or what Philadelphians now call the “Avenue of the Arts”— stands a well-appointed modern business hotel. With its spacious guestrooms boasting “pillow top” mattresses and its wood-paneled nineteenth-floor restaurant with sweeping views over Center City, the Hyatt at the Bellevue effortlessly combines contemporary luxury and old-world charm. That charm is evident the moment you step from Broad Street into the lobby area and glide across the polished floor to the reception desk, taking in the glittering chandelier overhead and the curved staircase with its elegant hand-worked marble-and-iron rails. However, if you care little for decor and have important business to attend to, the hotel also offers state-of-the-art conference rooms, plus an indoor jogging track, a full-length swimming pool, and a 93,000-square-foot sports club. For allergy sufferers or the hyper-health-conscious, the Hyatt at the Bellevue even has spotless “hypo-allergenic” rooms equipped with a high-tech air purification system designed to filter out allergens and other airborne irritants. “Enjoy a better night’s sleep and make the most of your travels in a Hyatt PURE room,” reads the hotel’s marketing blurb.
What is not mentioned anywhere on the hotel’s website is the thing the building is best known for, at least among members of Philadelphia’s baby boom generation. For in 1976, the Bellevue-Stratford, as the hotel was then known, was the site of one of the most baffling infectious disease outbreaks in history—an outbreak centered on the hotel’s air conditioning and water cooling systems.
The “Legionnaires’ disease” affair began on Wednesday, July 21, when 2,300 delegates from the Pennsylvania section of the American Legion and their families (some 4,500 people in all) began arriving at the Bellevue-Stratford for their annual four-day jamboree. It was the summer of the American Bicentennial celebrations, and the Legionnaires—many of them veterans of World War II and Korea—were looking forward to partying in style. Those who could afford it—perhaps five hundred in all—had checked into the Bellevue, taking advantage of the discounts on rooms negotiated by the Legion’s state adjutant, Edward Hoak, whose job it was to preside over the convention that year and glad-hand delegates.
Formed from the shell of the Stratford, which used to stand at the southwest corner of Stratford and Broad, and the Bellevue, which used to overlook the northwest corner, the Bellevue-Stratford had opened its doors to guests in 1904 after a two-year refit costing a staggering $8 million (about $20 million in today’s money). Billed at the time as the most luxurious hotel in the nation, it was designed in the French Renaissance style, with the most magnificent ballroom in the United States, four restaurants, 1,000 guest rooms, and lighting fixtures by Thomas Edison. By the 1920s, “the Grande Old Dame of Broad Street” had become a fixture of Philadelphia society and a favorite haunt of celebrities, royalty, and heads of state. Former guests included Mark Twain, Rudyard Kipling, Queen Marie of Romania, and General John J. Pershing. Every US president from Theodore Roosevelt on had stayed there, including President John F. Kennedy, who had visited the hotel in October 1963, the month before his assassination in Dallas. However, by the 1970s the Bellevue had fallen out of fashion and was struggling to compete with the new luxury chains. Indeed, despite the discounts negotiated by Hoak, many delegates complained that the food and drinks were overpriced. They also thought the air conditioning in the hospitality suites was substandard and did not like the attitude of the “snooty” staff.
Those who could not afford the Bellevue had opted for the nearby Ben Franklin hotel and other cheaper midtown options. However, nearly everyone had visited the Bellevue’s lobby to register and as all the principal conference events, from the Keystone Go-Getter Club Breakfast on the opening day, to the Commander’s Bicentennial Ball on the final evening, were held at the hotel, conventioneers and their families soon became familiar with its bars and hospitality suites. The Legionnaires loved a drink at the best of times, and with temperatures in Philadelphia that week in the high nineties, the suites were soon packed with delegates seeking to quench their thirst and cool off. To keep costs down, Hoak had arranged for delegates to supply their own alcohol and snacks, but he could do little about the hotel’s creaking air conditioning system or the ice supplies, which soon ran out.
The first intimation Hoak had that Legionnaires had been visited by something worse than a hangover came a week later when he arrived in Manor, Pennsylvania, a small town two hundred miles west of Harrisburg, for the swearing-in of new officers of Post 472 and was informed that six Legionnaires in the area were ill and that one had died. There was further grim news when Hoak returned to his home near Harrisburg and found a letter waiting for him from the wife of a close colleague informing him that her husband was ill with pneumonia and was not responding to treatment. A few hours later Hoak received word from his secretary that the man was dead. Next, Hoak called his assistant adjutant in Chambersburg concerning another matter only to learn that he was attending the viewing of Charles Chamberlain, commander-elect of St. Thomas Post 612 in south-central Pennsylvania, who had died suddenly following the convention. When Hoak called the former state commander of Williamsport to inform him of the three deaths, he learned that six other people from Williamsport who had also attended the convention were seriously ill in area hospitals. In theory this was not unusual. After all, the Legionnaires formed an elderly demographic and many were also heavy smokers and drinkers with underlying health problems. But two deaths and more than six hospitalizations in the space of a week struck Hoak as more t
han a little odd, and when he made further calls and learned that other delegates across the state were also ill, his alarm deepened.
Hoak was not the only person becoming concerned that weekend. On Saturday, July 31, Robert Sharrar, chief of Acute Communicable Disease Control for Philadelphia, had taken a call from a physician in Carlisle worried about a patient who had recently attended the Legion convention and who was complaining of a fever and a dry, hacking cough. A chest X-ray indicated the patient had bronchopneumonia of the lower right lobe. Sharrar told him it sounded like mycoplasmal pneumonia and advised him to draw blood and send it for testing to the state laboratory when it reopened on Monday. In the meantime, he recommended the doctor treat his patient with a fast-acting antibiotic. Sharrar was about to end the conversation when the doctor asked whether he knew of any other cases of pneumonia in Philadelphia in the past few days. Sharrar did not. That was when the doctor said that he had heard that a patient had recently died of pneumonia in Lewisburg, in northwest Pennsylvania. Sharrar immediately called Lewisburg Hospital and asked to be put through to the resident pathologist, who informed him that the victim was a Legionnaire and that the cause of death had been “acute viral . . . hemorrhagic pneumonia.”
Two cases of pneumonia in a city the size of Philadelphia was not unusual—in an average summer week Sharrar could expect twenty to thirty deaths from the disease. Nevertheless, the cases gave Sharrar pause for thought. In February, a new strain of swine flu had been isolated at a US Army base at Fort Dix, New Jersey, thirty-five miles northeast of Philadelphia. The flu had claimed the life of a young private and gone on to sicken several soldiers on the base. Tests showed the strain was closely related to the H1N1 virus responsible for the deadly “Spanish flu” pandemic. Fearing that the Fort Dix outbreak was the harbinger of a new pandemic wave, David Sencer, the director of the CDC in Atlanta, had urged the Ford administration to immunize the entire US population. As a CDC-trained epidemiologist, Sharrar had fully supported Sencer’s recommendation and was determined that Philadelphians would be among the first to get the flu shots. All he was waiting for was for Congress to approve the administration’s $134 million funding request and for politicians in Washington to agree to insurance to cover vaccine manufacturers worried about their liability should the vaccine prove to have adverse effects.
IN THE LATE VICTORIAN and Edwardian periods, pneumonia had been the most feared disease after tuberculosis and was nearly always fatal, particularly in the case of the elderly or those with compromised immune systems. Indeed, prior to antibiotics, lobar pneumonia had accounted for roughly one-quarter of all deaths in the United States.
However, this changed with Dubos’s discovery in 1927, in Avery’s laboratory at the Rockefeller Institute in New York, of an enzyme that decomposed the polysaccharide capsule of the pneumococcus, making it vulnerable to phagocytosis. Together with the isolation of the first sulfa drugs in the 1930s, treatment and survival rates for pneumonia gradually improved. The wider availability of penicillin in the late 1940s, and the discovery of new antibiotics such as erythromycin and doxycycline in the 1950s, coupled with better respiratory technology in hospitals, saw further strides in treatment and convalescent care. By the early 1970s the rate of hospital fatalities had fallen to around 5 percent, the level at which it remains today. The result was that pneumonia ceased to be an interesting field of research for young medical scientists. Instead, believing that the “conquest of epidemic disease” was imminent, researchers focused on cancer and chronic diseases associated with genetic conditions and modern lifestyles.
As the outbreak in Philadelphia would demonstrate, this was a mistake. While most bacterial pneumonias are due to the pneumococcus, pneumonia can also be caused by several other common bacteria, for example, Yersinia pestis, the bacterium of plague, and Chlamydia psittaci, the bacterium of psittacosis. Another common source of atypical pneumonias is Hemophilus influenzae, the bacillus that Pfeiffer blamed for the Russian and Spanish influenza pandemics, and Mycoplasma pneumoniae, a tiny organism midway between a bacterium and a virus. In addition, there had been several outbreaks of pneumonia for which a causal agent had never been identified. These unsolved outbreaks included an incident in 1965 at St. Elizabeths Mental Hospital in Washington, DC in which fourteen people had died, and an outbreak at a health department building in Pontiac, Michigan. Dubbed “Pontiac Fever,” the latter had caused an influenza-like illness in 144 workers and visitors to the building, including a team from the CDC. Although there had been no deaths and no recorded cases of pneumonia, guinea pigs exposed to aerosols of unfiltered water from the building’s air condenser unit developed nodular pneumonia. That suggested the presence of a bacterium-sized infectious agent. Unfortunately, all attempts to culture the pathogen from the water or from the lung tissue of guinea pigs failed, much to the CDC’s frustration. The result was that while the Pontiac and St. Elizabeths outbreaks were known to epidemiologists, the cases had never been written up. By contrast, everyone knew about the swine flu outbreak at Fort Dix because there was such a panic about it and the newspapers were full of the government’s vaccination plans. Perhaps that was why, on August 2, a physician from the Veterans Administration Clinic in Philadelphia telephoned CDC headquarters and asked to speak with someone from the National Influenza Immunization Program. He was put through to Robert Craven, a young Epidemic Intelligence Service (EIS) officer who, together with his colleague, Phil Graitcer, was manning the desk in Auditorium A, the “war room” set up by the CDC in expectation of a nationwide epidemic of swine flu. The physician had grim news: four Legionnaires admitted to his clinic had died of pneumonia over the weekend. All of them had attended the state convention in Philadelphia. In addition, some twenty-six other people who had been at the convention were also showing signs of “febrile respiratory disease.”
At first Craven and Graitcer dismissed the reports: four deaths from pneumonia was to be expected among such a large gathering of elderly people. However, within the hour the CDC officers had fielded several more calls from doctors and health officials in Pennsylvania telling a similar story, and by mid-morning the death count from pneumonia had reached eleven. Now that was unusual. As it happened, one of their colleagues, another young EIS officer named Jim Beecham, had recently been posted to the headquarters of the Pennsylvania State Health Department in Harrisburg. When Craven got through to him he learned that earlier that morning Hoak had issued a statement saying that at least eight of his members were dead and some thirty other Legionnaires who had attended the convention were ill with “mysterious symptoms.” Reporters wondered whether the cases were connected to swine flu.
Influenza typically has an incubation period of one to four days, and most healthy adults are able to infect others up to five to seven days after becoming sick. If the Legionnaires had caught swine flu at the convention in Philadelphia, then the first illnesses would have shown themselves around July 28. It also meant that officials could expect a second wave in the first week of August. Was that what was now happening? Had the long-feared swine flu outbreak begun? No one was sure, but with rumors mounting and pharmaceutical companies months away from being able to supply sufficient doses of vaccine, it was imperative that the CDC answer the question quickly. If nothing else, David Sencer’s reputation depended on it.
The person to whom it fell to investigate the outbreak was David Fraser, a 32-year-old graduate of Harvard Medical School who bore a striking resemblance to Bobby Kennedy. Tapped as a future director of the CDC, Fraser had recently been appointed head of the CDC’s Special Pathogens Branch and occupied a small windowless office five floors above the swine flu war room. There he presided over a crack team of epidemiologists, including the latest cohort of EIS graduates. Established in 1951 as an early warning corps against biological warfare, EIS is the CDC’s elite disease detection squad. As befits a group that takes pride in its ability to investigate outbreaks in any part of the world, its symbol is a globe with a worn-out shoe sole.
Every year, between 250 to 300 applicants compete for the privilege of seventy-five places in the EIS’s intensive, two-year training program. Candidates are recruited from every area of medicine and include doctors, veterinarians, virologists, nurses, and dentists. The emphasis is on applied epidemiological procedures, biostatistics, and the management of an outbreak investigation. Particular emphasis is placed on the study of old case files and the compilation of “line lists,” or charts, detailing each case and the distribution of infections in time and space. In addition, trainees are expected to learn how to gather pathology and serology specimens.
In keeping with the vision of EIS’s founder, Alexander D. Langmuir, the emphasis was on learning on the job. As Langmuir once told an interviewer, he liked nothing better than throwing EIS candidates “overboard” to see if they could swim; and if they couldn’t, he was happy to “throw them a life ring, pull them out, and throw them in again.” In short, EIS graduates would stop at nothing to get to the bottom of an outbreak. A few years earlier, for instance, Fraser had helped solve the mystery of a Lassa Fever outbreak in Sierra Leone that had very nearly killed one of his colleagues who tramped through villages trapping rodents in search of the presumed reservoir of the virus (he eventually traced it to a local species of brown rat). Another reason Sencer had picked Fraser was his reputation for diplomacy, something that Sencer knew would be needed when Fraser arrived in Harrisburg, the Pennsylvania state capital, and local health officials learned of the CDC’s interest in the case.