The Age of Plagues

It wasn't that long ago that medicine declared a victory over infectious disease. Now a raft of new and mutating bugs are at the door, and a declining public health system is in no shape to fight them.

The man--we'll call him Terry-- was 28 years old and lived in a small Minnesota town. He had a job, a car, perhaps a girlfriend; the record is silent about most of his life. What it does say is that one day in October, he began feeling nauseous. Eventually he went to his mother's house. He had thrown up and was running a fever. She went to work on her third-shift job. When she came home she found her son passed out under the coffee table. He was taken to the emergency room at the nearest hospital, where he was placed on a respirator and given fluids. His liver, kidneys, and lungs were all failing. Within a few hours, he was dead.

When the pathologists cut Terry up--standard procedure when an otherwise healthy person suddenly drops dead--they found little out of the ordinary, except some tiny anomalies around his heart. They were signs, along with his fever and nausea, that he'd had some kind of infection. But to this day no one knows what it was, and it's possible that no one ever will. The doctors who treated Terry didn't think of saving standard lab specimens--blood, throat washes, stool. By the time Mike Osterholm's office called, all the hospital had to offer was a little bit of tissue. It now sits in a vial in a freezer, waiting to be analyzed someday.

Osterholm's official title is state epidemiologist, and his job description involves tracking any disease that pops up with higher-than-expected frequency. Over the years, he's tackled outbreaks of hepatitis and measles, pneumonia and the flu; back in 1981, he was part of the first major meeting at the Centers for Disease Control that discussed a mysterious new condition then called "gay-related immune disease." His team at the Minnesota Department of Health was among the first to identify toxic shock syndrome and Lyme disease. They've carved out a national reputation as one of the best groups of microbe-hunters in the country.

Studying deaths like Terry's is a recent addition to the team's job. Only a few months ago, they likely never would have heard about it; a few years ago, they might not have thought much of it if they had. Infectious disease was a medical specialty thought to be on its way out. The people who got into it were considered to have a slightly anachronistic penchant for what Osterholm calls "a kind of Sherlock Holmes-type work." When he started, there were six people working in the state Department of Health's acute disease epidemiology section, including clerical aides and grad students.

Now, as everyone who's heard of Outbreak and The Hot Zone knows, the bugs are back. In movies and bestsellers, they star as exotic monsters invading from distant locales. The reality, for the most part, is more prosaic and closer to home. But it's not a bit less scary.

There are now 30 people in Osterholm's group, including doctors, microbiologists, and specialists in genetic testing. They don't have space suits, helicopters, and large incendiary devices; their labs, up in a nondescript building near the University of Minnesota, look like glorified high school science rooms. The only odd detail are wire baskets filled with petri dishes where dark smudges grow on translucent liquid. Yellow Post-its identify the contents as salmonella, e. coli, shigella, and "Other." A couple of refrigerators have biohazard symbols on them; another says "food only."

In the office wing a few corridors over, Osterholm can barely keep up a 20-minute conversation without interruption. "I'm sorry," he says as he picks up another call. "We're in the middle of an outbreak." A few dozen cases of salmonella, it turns out, centered around a restaurant; there's at least one of those every week. Earlier in the day, the department has also been notified that a local hospital has found a new kind of wound infection. There's a report on the first confirmed case of this year's flu, a few hepatitis cases, and another foodborne outbreak.

"There really isn't a need to go to the public about any of this," Osterholm says. "One of the things we try very hard to do is to never cry wolf. When you hear us talk about emerging infections, we're very careful so that we don't overwhelm people with what's really there. Because they'll say 'this can't be true.'"

Minnesota got a hint of "what's really there" this year, during a five-month period that began with a meningitis epidemic in Mankato, yielded an outbreak of "flesh-eating" Group A strep near Rochester, and witnessed two simultaneous outbreaks of the pneumonia-like Legionnaires' disease in Mankato and Luverne. All three fell into what medicine has come to call "emerging infections"--bugs that were unknown until recently, or old diseases behaving in odd new ways. Together the four headline-making outbreaks killed seven people; 20 more have died of invasive strep alone since then without attracting much notice.

But the scary thing--the one Osterholm fears overwhelming people with--isn't the bugs, and their apparent resurgence. It's the fact that epidemiology groups like his own are increasingly scarce. That insurance companies pay for fewer and fewer tests, and more and more people never get to see a doctor. That between funding cuts, poverty, and the health care crisis, the entire system set up
to prevent infectious disease is ripping at
the seams.

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