Facts and ideas from anywhere

BUBONIC PLAGUE IN SAN FRANCISCO

William C. Roberts, MD.

Plague has been on planet Earth for centuries. A 1665 outbreak of plague in London killed thousands. Bubonic plague appeared in a rural province in China in the late 1870s and festered there for 2 decades before making its way across the globe. By 1893, it had reached the city of Canton, where it killed thousands. From there the disease traveled along the Pearl River to Hong Kong and then onboard steamboats to the wider world. In China, some 10 million people died within a span of 5 years. By the end of 1910, another 5 million perished as the plague emerged in India, Australia, Scotland, and North Africa.

In 1894, the plague cause was identified as a tiny rod-shaped bacterium known as Yersinia pestis. How it was spread, who was most likely to contract it, and whether any medication could halt its progress were still unknown. A few upper-class foreigners living in colonial compounds in Hong Kong and India never caught the disease even as thousands around them succumbed, causing some public health officials to conclude that those with European ancestry had somehow developed immunity to plague and to point to their survival as racial superiority. In 1897, Europe imposed travel restrictions on most goods and people but allowed upper-class whites free passage from plague-stricken areas while denying entry to everyone else.

In 1900, the plague appeared in Honolulu, Hawaii, and the board of health initially quarantined those living in Chinatown. That proved ineffective and the next step was to burn Chinatown, which they did on the final night of the 19th century. The fire also proved ineffective.

David K. Randall, a senior reporter at Reuters, in his splendid book entitled Black Death at the Golden Gate, describes vividly the San Francisco plague epidemic in the first decade of the 20th century.¹ It began with Wong Chut King, who lived in squalid conditions in the cellar of San Francisco’s Globe Hotel. It was a rat-infested space in the city’s Chinatown that he shared with as many as three roommates, all taking turns sleeping on the same bed. When a painful lump appeared on Wong’s groin, the 41-year-old laborer consulted a local Chinese doctor who prescribed an herbal remedy. Wong became nauseous, diarrheic, and delusional. His temperature soared. His roommates took him to a nearby coffin shop where he died on March 6, 1900, as the city’s first known victim of bubonic plague.

Randall describes in chilling detail how the disease can overwhelm the human body. He describes the unsanitary conditions in the city’s Chinatown, where large colonies of flee-ridden rats scavenged for food. Not long after Wong Chut King’s death, local crab fishermen found two bodies floating in the San Francisco Bay. They had been on the Nippon Maru, a ship suspected of carrying passengers from Asia infected with plague. City officials soon confirmed that the corpses were plague-ridden. In San Francisco, Joseph Kinyoun, a member of the Marine Hospital Service, a precursor to the modern US Health Service, was in charge of eliminating the epidemic in the city, and he quarantined Chinatown. He had been one of the most accomplished scientists in the USA. The number of deaths in Chinatown rose steadily. Kinyoun repeatedly clashed with local officials who were reluctant to admit that the plague had arrived in their midst and were eager to lift a temporary quarantine imposed after Wong’s death. By early 1901, the plague had claimed 26 victims in 10 months, almost all of them in San Francisco’s Chinatown. Unfortunately, the brilliant but socially inept Kinyoun antagonized so many officials in the city that he was almost run out of town.

Rupert Blue, a 32-year-old Marine Hospital Service physician, replaced him in the late spring of 1901. In contrast to Kinyoun, he was tactful and amiable and had manners befitting a South Carolinian, where he grew up. At a time when the Chinese were widely discriminated against, Blue hired a Chinese translator and aide, Wong Chung, and treated him as a full member of his staff. Wong proved effective at working with both the Chinese community and local health authorities in ways that Kinyoun had not.

Blue was aware of the work of Paul-Louis Simond, a French researcher, who had noted that the bodies of patients treated at an early stage of plague all had one or more small blisters that contained a mix of fluid and plague bacilli. These blisters, the size of an insect bite, were followed by the emergence of buboes in the lymph nodes of the groin, neck, or armpits. Convinced that insects were spreading plague through their bites, Simond went searching for what species were capable of transferring the disease, not just from person to person but also from rat to rat. He began dunking dead rats found in the homes of plague victims into a bin filled with soapy water, where he would rifle through their fur with his bare hands and pick off as many fleas as he could. When he examined the insects’ intestines under a microscope, he found that the fleas were saturated with plague bacilli.

The following year, Simond tested his theory in Saigon with live rats he had caught in the homes of plague victims. He placed a flea-infested animal in a small metal cage that was not quite large enough for it to turn around in. He placed another cage of a similar size containing a healthy rat that had not had prior exposure to the plague next to the flea-infested rat cage. Wire-meshed walls and a thick layer of sand under each cage prevented contact between the animals and isolated their droppings. Six-millimeter holes in the cage screen allowed fleas to travel between them. The rat taken from the home of a plague victim died on the second day of the experiment. Simond let its body sit for an additional day before removing it, giving fleas time to abandon the corpse and jump across the barrier to the still healthy rat sitting nearby. An autopsy of the dead rat revealed an abundance of bacilli in the blood and organs. The healthy rat, now host to the fleas from its dead neighbor, continued to eat normally for 4 more days, at which point it seemed to have difficulty moving. By the following evening, it too was dead. An autopsy revealed plague bacilli in the kidneys and liver. That day was June 2, 1898. Five years later, in 1903, French physicians working in Marseille proved that plague could not be transmitted among rabbits without the presence of fleas, confirming Simond’s suspicion that the insect bites had caused millions of deaths throughout history.

A small bit on the rat. It is the most common mammal in the world, living in close proximity to every known human habitation. It is an excellent swimmer, is blessed with a sense of smell that can detect poison in food down to the level of 1 part per million, and is equipped with teeth that are stronger than iron. Its skeleton can collapse, permitting it to fit through a hole the width of its skull. That level of mobility makes it an ideal urban dweller, able to enter and escape spaces that otherwise seem impenetrable. A rat can scale nearly vertical walls made out of virtually any material, and once it nears the top, it can jump more than 4 feet horizontally, allowing it nearly unlimited range in a city. Should it fall, it can easily survive a tumble from a height up to 50 feet, roughly equivalent to a 5-story building. If climbing is not possible, digging is. Rats can dig dense underground labyrinths, as far as 2 feet below the surface, and are able to move swiftly through pitch-black spaces by using their whiskers to guide them. Once introduced into a new environment, rats expand their numbers by a hyperfertility rate that can produce 15,000 descendants within a year from a single pair of rats. In environments densely laden with trash, rat populations can easily swell into the millions.

Not long after Blue arrived in San Francisco, he began exploring Chinatown and speaking with Chinese residents—the first time that an officer in the Marine Hospital Service had attempted to forge a personal connection. His genial nature seemed to broadcast the sense that he was trustworthy, and he soon opened doors that had long been closed to other white physicians. In his first week, he discovered cellars filled with years of accumulated sewage and decaying bodies of rats. While investigating an alley, he came upon more than 150 pounds of rotting meat lying in the open, overrun by the squirming bodies of rats and swarmed by insects.

In contrast to his predecessor Kinyoun, who was most comfortable in a laboratory removed from the complexities of human interaction, Blue thrived in a situation where trust and tact were essential. Kinyoun had paid an almost fanatical attention to rules, whereas Blue proved willing to look at problems from all angles, searching for anything that might work, however unorthodox it might be. Blue’s first move in San Francisco was to lease a small office in an alley off one of Chinatown’s squares. There, in a two-room space, he set up a makeshift laboratory and morgue, finally providing the Marine Hospital Service with an outpost in Chinatown itself. To solve the issue of bodies disappearing from the district before they were examined, he established his own hearse service—a horse and cart—where a driver could go to any building in Chinatown as soon as a body was reported. The cadavers were transported back to Blue’s new laboratory, where they were examined before anyone had a chance to hide them.

Soon he got wind of several prostitutes in Chinatown who had developed large painful buboes on their groins 6 days earlier and now lay comatose with fever. Blue confirmed that each of the three women had bubonic plague. The Marine Hospital Service officers learned that the three prostitutes who had died from plague had collectively had sex with at least 50 men, including several who had lived outside Chinatown, in the days before their buboes appeared, thus expanding the zone of potential victims beyond the bay.

The plague’s apparent summer lull was broken just before Labor Day, when the body of a Chinese man was discovered. The corpse was brought to Blue’s morgue, where an autopsy revealed plague.

In 1902, Rupert Blue had had enough and asked the surgeon general to send him to another location. By 1903, however, the numbers of plague victims in San Francisco had increased and Blue was reassigned to San Francisco. He moved back to his old office at the edge of Chinatown and took charge of the largest sanitation campaign in San Francisco’s history. Over the following weeks, he sent horse-drawn wagons carrying barrels of disinfectant up and down the district’s cobblestone streets, spreading more than 26,000 pounds of white lye powder. State health officials soaked the cellars of every building in Chinatown with carbolic acid and washed down the walls and floors with a solution of mercury bichloride and lye, leaving the neighborhood smelling like rotten eggs. Workers laid asphalt on Chinatown’s main thoroughfare to allow the city’s first street sweepers to motor down it three times a week. He sent inspectors accompanied by interpreters into each building in Chinatown to record the number of apartments it contained and the health status of their occupants, providing the federal physicians with the first accurate census of Chinatown and a rudimentary way to keep track of plague victims. Unlike Kinyoun, Blue’s insistence upon total compliance with Chinatown’s residents led him to escalate his prophylactic measures. However, Blue remained measured. He had worked in this district long enough to accept that some of the hostility toward health officials was valid and that providing further confrontation would only come back to harm him. Instead, he relied on a trial-and-error process that forced him to look for new approaches. For 3 years, federal doctors had demanded sanitation measures that had thus far proved ineffective at eradicating the disease. Blue therefore turned his attention to rodents, determined to discover whether the throngs of flea-infested rats that swarmed through the district—rather than simply the filth—were the true reasons that the disease persisted.

Though Blue knew of Simond’s work on the role that rats and their fleas played in spreading plague, no city had yet tried to act on it. He ordered his men to install hundreds of traps in Chinatown’s sewers baited with arsenic-laden cheese. Autopsies were performed on the bodies of >300 rats. None of the rats showed signs of plague in their lungs or buboes in their glands. Nevertheless, focusing on killing the rats was a new way to combat the crisis. Blue directed the sanitation effort toward the specific goal of eliminating disease, largely by targeting the environments that allowed rats to multiply. Dilapidated balconies, rotting planks of wood, and makeshift additions to buildings were torn down throughout the district to eliminate places for rodents to nest. Soon, sunshine began filtering down into the district’s narrow alleyways, eliminating the persistent smell of musk. The additional natural sunlight proved to be a deterrent to rats, which have an innate fear of bright light. (The plague bacterium could be killed by ultraviolet light alone.)

Health officials discovered the first new plague victim 6 weeks after Blue arrived, underscoring the reality that a simple cleanup would not be enough to ensure the city’s survival. The dry summer months lay ahead, a time of year when rats would leave their nests in search of new sources of food and new mates. He redoubled his efforts to eliminate as many rodents as possible before the breeding season. He instituted a policy that he called “building out” that for the first time required landlords to take responsibility for how their properties contributed to the spread of disease. He directed his attention initially to rat-infested cellars. Property owners were ordered to pour a layer of concrete on their cellars or ground floors, which often set on nothing but packed earth and offered a warm, dry place for the rodents to build nests. He ordered broken drains fixed, cesspools filled in, and any holes in a building’s walls patched. Property owners who did not immediately comply received notification that the city would happily demolish the structure instead. Nearly 200 wooden buildings in the district were destroyed, with modern brick and concrete structures rising in their place. Stacks of discarded wood lay in the streets, remnants of razed buildings.

Blue also began concentrating more of his efforts on the Latin Quarter. He sent health inspectors into apartment buildings where no Asian resident had ever lived and demanded the same rat-proofing measures as in Chinatown. Concrete was poured on the basement floors and debris was cleared from drains and closed off, eliminating potential homes for rats. Blue hired additional men to serve as rat trappers, laying poison traps throughout Chinatown and the Latin Quarter. Blue began offering a bounty of 10¢ for every rat, living or dead, brought to his Chinatown laboratory. Each one was nailed to a roof shingle and autopsied, then tossed into a metal garbage can and incinerated. Though the disease was still not contained in Chinatown, Blue turned his attention to the rural expanse of the East Bay. Hearing rumors of a massive “die-off” of squirrels on several farms, he traveled out to the area intent on finding evidence for himself. Laboratory studies had demonstrated that, like rats, squirrels could be infected with the disease through the bites of contaminated fleas. He was unable to find any dead squirrels in the rural areas.

Back in Chinatown, four victims of plague were discovered in October 1904, and the following month three more cases were identified. Blue could not make sense of the epidemic pattern, which would strike several patients at once and then disappear. Physicians found no additional victims in December, only to discover three cases in January 1905. The death of a white family outside Chinatown from the most virulent form of the disease forced Blue to question whether his focus on rats had simply made the situation worse. There were now noticeably few rats in Chinatown, but Blue feared that his strategy of “building out” plague had brought infected rats outside of Chinatown, bringing death with them. He ordered additional inspections of every building in the Latin Quarter with the focus on rats. After a demolition crew discovered the bodies of 82 rats lodged in the walls of a Chinese restaurant in the neighborhood, Blue directed his officers to place bait in warehouses, stables, and restaurants throughout the district to remove easy sources of food. Dead rats soon began piling up in the basements of apartment buildings and along sewer lines. The bodies were gathered up by either health officials or scavengers who brought them to the Chinatown laboratory to collect their bounty. Marine Health Service agents resumed the process of slicing open each one and looking for signs of plague.

The sudden willingness of white physicians to admit that they, too, had treated cases of plague confirmed Blue’s fear that the disease had been spreading secretly throughout the city. Yet, he welcomed the help. He expanded the rat-proofing campaign by ordering property owners in the Latin Quarter to demolish old wooden buildings and replace them with brick and steel. The number of plague-free months began to climb, a drop that Blue believed was in large part due to the work of his men eliminating hundreds of thousands of rats from streets and sewers. By early 1905, it appeared that the epidemic in San Francisco was eradicated and Blue was transferred to Norfolk, Virginia. Since the first known case of the outbreak in 1900, plague had infected 121 confirmed victims in San Francisco and the surrounding area and caused 113 deaths.

On April 17, 1906, a 42-second earthquake essentially flattened San Francisco. By the time the ground stopped moving, more than 30,000 buildings were gone. By the end of the first week, more than 80% of San Francisco’s buildings were destroyed and more than 250,000 people were living in the city’s parks. The army built 26 official refugee camps, with an isolated camp built for residents of Chinatown. On April 21, 1906, Rupert Blue received orders to return to San Francisco. Danger from the earthquake and fires had passed. The chief concern now was disease. Rats were already running free in the refugee camps where discarded food lay rotting. The stench of untreated human waste sitting in shallow, hand-dug holes wafted throughout the city on winds whipping off the bay. Without proper sanitation and clean drinking water, deadly diseases like cholera and typhoid were sure to spread, if they had not done so already. Twenty cases of smallpox had been identified in Oakland.

As soon as he arrived in San Francisco, Blue made his rounds and was shocked by what he saw. Human waste saturated the ground, and rats darted in and out of tents. Fearing the spread of cholera from the open sewage, Blue disbanded the sick camp and sent the residents elsewhere. Instructions were the same at each camp: latrines needed deeper holes, screens had to be installed to protect food from flies, and trash collection systems had to be implemented as quickly as possible. Despite Blue’s fears, no major illnesses swept through San Francisco in the aftermath of the earthquake and fires, dispelled in part by the sanitary measures that he and the army medical officers implemented.

On May 27, 1907, 13 months after the earthquake, a new case of bubonic plague appeared, and in a span of less than a week, six other victims were diagnosed in the city. Chinatown, the center of the first outbreak, seemed to be the only neighborhood spared. By this time, Blue had returned to Norfolk, Virginia. Unable to focus their attention on a single neighborhood, health officials felt pulled in every direction, not knowing where the next victim might emerge. There was no neighborhood to quarantine, no community to target, and little hope of walling off the disease. For the first time since the plague had appeared in the city 7 years earlier, it felt like all of San Francisco was at risk. All of the recent victims were white, proving that the plague was not restricted along racial lines.

The surgeon general contacted Reginald Blue again and ordered him to report to San Francisco immediately. On September 6, Blue and his team were on their way to San Francisco. The plague in the meantime was racing through the city, killing its victims with alarming speed. By the time Blue and his men arrived on September 12, health officials had identified 25 cases of the plague since the start of August, with 13 of them fatal. There seemed to be no pattern, no clues as to where it would strike next. This time Blue had no headquarters, no laboratory, no medical equipment. San Francisco was roughly a 50-square-mile peninsula made up of valleys, hills, forest, and sand dunes; densely packed neighborhoods; and crowded stables. On this occasion, Chinatown was the only part of the city not teeming with rats, a fact that Blue attributed to the poison and other measures he had put in place roughly 2 years earlier. Blue set about purging all of San Francisco of its rats without regard to human race or ethnicity. As in most cities, rodents were considered part of the natural urban landscape and not a harbinger of disease. Rats were such an everyday part of city life that construction workers rebuilding office towers downtown would toss leftover food from their lunches into the vacant lots knowing that the rats would clean up after them. The wrecked city provided infinite nesting places, allowing the rat population to expand without constraint.

Blue divided the city into 13 districts and unleashed teams of rat chasers into each district. He also urged residents to set out traps and poison, seal their garbage in rat-proof containers, and seal every rat hole as soon as they saw it. Health inspectors visited each property twice looking for rats. Clad in heavy pants, tall boots, and leather gloves, they clenched the cuffs of their pants around their legs with string before entering a specified area, aiming to give fleas no exposed skin to bite. The inspectors would note the number of rats taken from each location, the gender of each animal, and the date the house had been visited before. Living rats were tossed into vats of boiling water, a tactic meant to quickly kill fleas clinging to their bodies. Each carcass was nailed to a wooden shingle and given a number along with a short description of where it was caught. As the bodies of thousands of rats piled up inside the house, federal doctors wearing rubber gloves stood before long dissection tables and sliced open the chests of each corpse. They peeled back the skin of the animal to inspect its glands and spleen, searching for buboes that suggested plague. When a rat appeared to have the disease, a bacteriologist plucked it from the line with metal tongs and took additional tissue samples. After the culture was prepared, suspected plague cells were injected into guinea pigs to confirm the diagnosis. Soon, physicians were filling 10 steel garbage cans a day with splayed rat carcasses that were then tossed into an incinerator.

Despite these measures, the disease kept spreading. A second-wave death toll reached 65 by December 1907. Blue’s men were catching and killing more than 13,000 rats a week, yet that seemed to barely dull the ferocity of the disease. It was not long before Blue realized that he would be unable to control the plague epidemic without the cooperation of the citizens of San Francisco. Therefore, he began speaking to any group that would listen. His message was that to prevent quarantining the city of San Francisco, everyone would have to cooperate and help kill rats. His rat catchers continued to bring dead rats to his laboratory, and about 1.5% of the rats had bubonic plague. The hours that Dr. Blue spent talking with audiences and answering their questions about the plague made San Francisco residents and officials more comfortable and more willing to help. To spur ordinary citizens to kill rats, they began offering bounties of 25¢ for every male and 50¢ for every female rat brought to a field office, a ploy that turned gangs of boys across the city into amateur killing squads. Blue shook San Francisco out of its habits, leaving a newer, more sanitary version in its place. With his continued campaign, they went 6 months without another plague victim.

In October 1924, a plague epidemic hit Los Angeles, and again Blue was contacted to take charge. Blue implemented the same control measures he had developed in San Francisco and New Orleans. Houses were stripped of their sidings to prevent rats from building nests; garbage collections were increased, starving the animals of their food; poison was applied liberally throughout the city and along the wharves. Blue sent teams of men into the rural expanses of Los Angeles County searching for squirrel holes, which they dynamited and poisoned. Property owners were ordered to spend what soon amounted to more than $2 million on retrofitting their buildings with concrete, razing the few remaining wooden structures, which had survived as relics of the city’s past.

Blue stayed in Los Angeles for 7 months. By the end of his time there, health officers under his supervision had sliced open the bodies of 106,951 rats, finding 187 that tested positive for plague. An additional 16,094 squirrels passed through Blue’s laboratory, with 9 of them infected with the disease. No new human victims had the disease. Los Angeles would prove to be the last major outbreak of plague in the country.

The plague has never been fully eradicated in the USA. The disease strain, carried by fleas, that first infected squirrels in the hills above Berkeley went deeper into the continent, eventually becoming entrenched in rodent populations throughout the West. Two visitors to Yosemite National Park developed plague in the summer of 2015, and multiple patients developed the disease in Arizona and New Mexico in the summer of 2017. An average of seven people in the USA now contract plague every year. Patients whose conditions would have quickly proved fatal now receive treatment with streptomycin, which was unavailable in Blue’s time.

HOT DAYS INCREASING

A study just published in the journal Environmental Research Communications projects that planet Earth will experience large increases in intense heat by 2050.² The major reason for the increasing heat waves is our failure to reduce heat-trapping emissions from burning fossil fuels. Three of the five US cities that are expected to see the largest increases in extremely hot days are Brownsville, McAllen, and Harlingen, Texas. Dallas ranks number 53 of the 481 cities assessed. The number of days with heat indexes higher than 105°F will increase. At a heat index of 104°F or higher, heat stroke generally starts to become a serious possibility, in contrast to heat exhaustion, which usually can be cured by cooling off in the shade and drinking water. A heat stroke is an emergency and must be quickly dealt with because it can be fatal. Mortality is especially high for infants and the elderly. Even under the most optimistic projections, Dallas is expected to see about 45 days every year with a heat index of 105°F or greater. Dallas so far has endured only a week’s worth of such hot days. The projection assumes that the world’s carbon emission will start to collectively decline by 2040. The most dismal assumption is that the world takes no action to address climate change. Under that forecast, Dallas is looking at 60 days per year above a heat index of 105°F by mid-century and over 3 months by the century’s end. The study also predicts that Dallas will start to see a couple of days each year with heat indexes much greater than 105°F, such as heat indexes above 127°F.

Enjoy our present 100°F days, which will be a blessing in future years.

HISTORY OF US CENSUS TAKING

John Steele Gordon, the author of “An American Empire of Wealth: The Epic History of Economic Power” in the June 2019 issue of The Wall Street Journal, described some of the history of census taking.³ The earliest known census was conducted in Egypt from 2050 to 1700 bc. The Old Testament book of Numbers refers to a census of the Israelites, and the New Testament in Matthew tells us that Jesus was born in Bethlehem because Joseph had to travel there to register for the Roman census.

The US Constitution mandated a census within 3 years of the first Congress and every 10 years thereafter to apportion the House. The first census was taken in 1790 and the 23rd in 2010. These 23 censuses reveal much about US history. The American population grew with enormous speed—at least by a third in every census from 1800 to 1860. With the exception of the 1930s, when both immigration and the birth rate fell sharply, population growth was never below 10% per decade until 2010, when the increase was 9.7%. Today’s US population is 84 times that of 1790.

Only three states have ever been the most populous in the union: Virginia (1790–1800), New York (1810–1960), and California (since 1970).

There has been a profound shift in the population from the Northeast to the South and West. The Mid-Atlantic states have lost 30% of their House seats since 1950, whereas the old Confederate states have gained 30%. Florida’s delegation has more than tripled.

In the early censuses, only the heads of household were included, along with the total number of everyone living there, including slaves. Beginning in 1850, the names of everyone in the household were listed, a bonanza for genealogists. Families moved westward, often more than once, pushing the frontier back. By 1890, the frontier had ceased to exist.

As both the population and the number of questions asked continued to expand, crunching the numbers became ever more time consuming. It took, for example, 8 years to complete the analysis of the 1880 census.

In 1889, Herman Hollerith, a professor at the Massachusetts Institute of Technology, invented an electromechanical tabulating machine that used punch cards. He founded the Tabulating Machine Company, an ancestor of today’s IBM. The Census Office immediately adopted the technology and was able to complete the 1890 count in a mere 6 weeks.

The US population passed 100 million in 1920, 200 million in 1970, and 300 million in 2010. Even with mechanization, the massive amount of data was becoming unwieldy. Starting in 1950, one in six households got a long census form, asking detailed economic and other questions. In 2010, the American Community Survey replaced the long form and was conducted in the years between the bicentennial censuses. The 2010 census cost $13 billion, about $42 per person.

DALLAS–FORT WORTH POPULATION

Dallas–Fort Worth has gained more residents in the past 8 years than any other metropolitan area in the country—more than a million people.⁴ The region’s population now tops 7.5 million, making North Texas the nation’s fourth largest metro area, trailing only New York City, Los Angeles, and Chicago, all of which are losing residents. New data from the US Census Bureau show that Texas gained >3.5 million people from April 2010 through July 2018. That is the equivalent of 1000 new residents a day, with a third of them settling in Dallas–Fort Worth.

During the same 8 years, the Houston region added 1 million new residents; Austin’s metro area grew by just under 400,000; and the San Antonio–New Braunfels area gained 375,000 people. People moving to Texas from other states accounted for more than 1 million new residents—the most domestic transplants of any state except Florida.

Surrounding counties in the Dallas–Fort Worth area grew at nearly twice the rate of Dallas County. With a 30% increase in residents from 2010 to 2018, Denton County was the 19th fastest-growing county in the nation, followed by Rockwall County at 20th and Collin County at 21st. Without out-of-country migrants, Texas would have grown by 800,000 fewer residents. Only Florida and California had a greater number of international migrants. Immigration was the primary driver of population growth for about 1 in 10 counties nationwide. In Dallas–Fort Worth, Asians accounted for an increasing number of immigrants. About one-third of Texas counties lost population over the 8-year period tracked.

The most extreme population loss occurred in rural areas such as the Panhandle. Most of the decline was probably driven by young people leaving for jobs and education opportunities to urban areas, which affects birth rates. About 3 million people live in rural Texas, and “us” urban folk depend on them for food, fiber, and fuel.

CHANGING DALLAS–FORT WORTH’S POPULATION

The US Census Bureau described changes in the population in the Dallas–Fort Worth area from 2010 to 2018.⁵ During this 8-year period, the white population grew 3.45%; the Hispanic population, 2.19%; the black population, 1.9%; and the Asian population, 0.45%. The Hispanic population accounted for 40.5% of the region’s gain from 2010 to 2018; that of blacks was 25.3% and Asians, 20.7%. Since 2010, the Asian population in the Dallas area has grown 56%. The non-Hispanic white population only contributed 9.4% to the growth during the 8-year period. These new figures confirm demographers’ prediction that Hispanics will become the state’s majority by 2022. Because of higher fertility rates than those among the white and black residents, Hispanics have played a key role over the past 5 decades in reshaping Texas’s demographics. Latinos also have provided a steady workforce that has made the state attractive for businesses looking to resettle in this pro-business state. Texas added about 3.5 million residents from April 2010 to July 2018. North Texas added >1 million residents in that time, mostly due to natural growth as well as international migration.

FASTEST GROWING TEXAS CITIES

From July 1, 2017, to July 1, 2018, Texas had seven of the fastest growing cities in the USA with a population of at least 50,000.⁶ These seven include New Braunfels, 7.2%; Frisco, 6.1%; McKinney, 4.5%; Georgetown, 5.2%; Rowlett, 5.1%; Midland, 4.4%; and Round Rock, 4.4%. All of that growth occurred in a single year.

MALE FATHERS

In its 2014 report, for the first time, the US Census Bureau asked both men and women about their fertility histories.⁷ It found that more than 60% of the 121 million adult men in the USA were fathers. About three-quarters of the fathers were married, almost 13% were divorced, and 8% had never married. Just under one-quarter of US men between the ages of 40 and 50 years were childless, and about 17% had never been married by the time they were in their 40s. For women, just under 16% between the ages of 40 and 50 were childless, and 14% had never been married. For those whose youngest child was under 6 years old, 90% of fathers and around 60% of mothers were employed. Men with children tended to be more educated than those without children. Of men in their 20s, almost 30% of Hispanics were fathers, about 25% of black men, just over 20% of white men, and an eighth of Asian men. By their 40s, more than 83% of Hispanics were fathers, about 80% of black and Asian men, and around 75% of white men.

DRIVING IN THE DALLAS METROPLEX

Each year, the Allstate Insurance Company analyzes the accident rates of about 200 cities in the USA.⁸ The Dallas area falls in the bottom 15% of cities for safe-driving records. On average, Dallas drivers have a collision every 7 years, meaning that they are 46% more likely to be involved in a wreck than the average US driver, who experiences a collision once every 10.5 years. North Texas landed in the bottom half of Allstate’s ranking of 200 large US cities based on auto claims data. The Dallas area alone ranked 172 of the 200 cities. The Texas cities of Brownsville, Laredo, and McAllen were the safest in the USA for drivers. Texas also leads the nation in traffic deaths. At least one person has died on Texas roads every day for the past 19 years. On average, 10 people die on Texas roadways each day.

HOMICIDES IN DALLAS

There were just over 100 homicides in Dallas during the first 6 months of 2019, an increase from 2018.⁹ There is a view that we need more police officers in the city, and our city government is trying to meet that goal.

GUN VIOLENCE IN THE USA

The number of students who have experienced a shooting on campus during school hours since 1999 (18 years) totals 187,000.¹⁰ The number of Americans shot annually, including murders, assaults, suicides and suicide attempts, unintentional shootings, or other gun violence, totals just over 116,000. The number of deaths annually from gun violence totals 35,000. Of the millions of gun owners in the USA, only 38% are recreational hunters.

PROVIDING OUR LOVED ONES WITH OUR ESTATE PLANS AND HEALTH CARE DIRECTIVES

Liz Weston¹¹ provided three websites to obtain needed information on estate plans and health care directives.

Whealthcare (whealthcareplan.com) allows its users to answer questions on the website to create a “financial caretaking plan” that identifies the issues our loved ones are likely to face as they age. The service also provides a transition plan that allows trusted people to take over and a customized “to-do” list to make sure that crucial documents are in place: powers of attorney and health care directives, for example. Another assessment gauges a person’s risk for fraud, exploitation, and bad financial decision making and offers recommendations for protecting against those threats. The annual cost is $99 for one individual.

Everplans (everplans.com) is an online vault where one can store important documents, contacts, login credentials, and instructions on what to do with social media sites and anything else your family might need to know to handle your affairs. The site offers step-by-step guidance to identify and organize this important information, from insurance policies to pet care plans. The cost is $75 per year.

EverSafe (eversafe.com) monitors financial accounts for unusual activity, large transactions, and other potential problems. The site gives alerts via email, text, or automated phone calls and can be set up to signal trusted others as well. The basic service, which costs $7.59 per month, monitors bank and credit card accounts and one’s personal information. For $14.99 per month, one can add credit monitoring. For $24.99 per month, the site will monitor investment accounts as well.

BOOSTING HAPPINESS

A study published in Nature: Scientific Reports reported that spending 2 hours a week outdoors (i.e., strolling a tree-lined street or sitting by a lake) could enhance a person’s overall sense of well-being.¹² Those doing so were about 20% more likely to report high overall satisfaction with their lives than those who spent no time outdoors at all. The benefits to physical health were even greater, with those who met the outdoor benchmark being 60% more likely to report being in good health than their cooped-up counterparts.

OUR DEFENSE BUDGET

Jessica T. Mathews, writing in The New York Review, argues that too much of our national budget is spent for defense.¹³ Defense spending accounts for 60% of the federal discretionary budget—that is, all federal spending other than the mandatory allotments for entitlements (Social Security, Medicare, Medicaid, etc.) and interest on the national debt. Discretionary spending covers everything else the government does: paying for the military, the federal judiciary, and law enforcement; supporting infrastructure, education, and agriculture; investing in science and technology; protecting the environment, wilderness, and national parks; managing relations with the rest of the world and with international organizations overseeing everything from trade to arms control; funding the National Weather Service; policing the borders and exploring space; developing energy resources; and ensuring the safety and soundness of food, drugs, communications, airline travel, consumer products, national banks, and the stock exchange, among others. Since 2011, the defense budget has increased every year. After the Korean War, the defense budget dropped 20%; after the Vietnam War, it dropped by 30%; and after the Cold War ended in 1990, the military workforce was reduced by 26%. The yearly increases during the last 18 years were originally supported mainly by the Republicans but in recent times have been supported by both parties.

Mathews argues that the Defense Department has a nonfunctioning accounting system. Many experts believe that the waste is at least $25 billion each year. The number of personnel who support each combat soldier is the highest of any country. The army has 6000 tanks—far more than it needs for any conceivable future combat—and they are continually being built. Likewise, aircraft carriers, costing $13 billion each, are being built, and many believe that they are increasingly vulnerable to attack by high-speed maneuverable missiles that can be bought for a fraction of what a carrier costs. The Department of Defense maintains 136 military bands, with more than 6500 full-time positions, at an annual cost of $500 million. The funding for these bands has not diminished despite an estimated $250 million in annual savings that could be realized by doing so. The Defense Department budget amounts to 3% to 4% of our gross domestic product. (In 1944 it was >40%, during the Korean War >15%, and in the early 1960s 10%.)

If the USA faces acute threats, allocating 60% of the government’s unrestricted funds to defense might be necessary. Currently, however, we do not face an acute threat, but we still spend more on defense than the next eight largest spenders combined: China, Saudi Arabia, India, France, Russia, the United Kingdom, Germany, and Japan. We spend a higher proportion of the federal budget on defense than on domestic needs. In addition, this spending does not necessarily buy useful capability and it increases the federal debt. We probably spend too little on cyber and space technology, however. With 60% of our discretionary budget going to defense, that, of course, leaves inadequate monies for medical care, medical innovation, medical education, and medical training.

HERBERT LEONARD FRED, MD (1929–2018)

He was born in Waco, Texas, in a warm family; he was valedictorian of his high school class; he graduated from Rice Institute (now Rice University) and from the Johns Hopkins University School of Medicine; he trained in internal medicine at the University of Utah–affiliated hospitals in Salt Lake City, where his beloved mentor and department chief was Maxwell Myer Wintrobe (1901–1986); he joined the faculty of Baylor University College of Medicine (1962) and, from that time until his death, he was a beloved bedside teacher of medicine at several Houston medical centers and received numerous teaching awards; he is the author of 6 books and 450 publications in medical journals; he was a lifelong chronicler and left his 88 boxes of papers stretching 112 cubic feet in length to the Houston Academy of Medicine–Texas Medical Center Library; he was an editor of two different medical journals; from 1966 to 2013 he ran 253,000 miles; he had three children by his first marriage and four stepchildren by his second marriage of 40 years; he mentored hundreds of medical students and medical house officers during a vigorous teaching schedule. His name is Herbert L. Fred (Figure 1).

Figure 1. Herbert Fred, MD.

During his 50+ years as a full-time medical educator, he carried on the tradition of William Osler, who emphasized the importance of basic clinical skills practiced at the patient’s bedside. Like Dr. Osler, Dr. Fred was a prolific author. His books offer many memorable sayings, pithy aphorisms, and clinical pearls. His publications are all superbly written, lively, humorous, and written in a conversational style.

The following four paragraphs essentially summarize what Dr. Fred was successful at:

We need more teachers who learn to make diagnoses by understanding the pathophysiology, clinical features, and natural history of diseases. They know what tests, if any, to order, when to order them, and how to interpret them. And they use advanced technology to verify rather than to formulate their clinical impressions.

These are the teachers who truly comprehend the value of a good medical history, the rewards of a pertinent physical examination, and the power of knowing how to think. These are the teachers who still routinely use the stethoscope, not an echocardiogram, to detect valvular heart disease; who use the ophthalmoscope, not magnetic resonance imaging, to detect intracranial hypertension; who use their eyes, not a blood gas apparatus, to detect cyanosis; who use their hands, not computed tomography, to detect splenomegaly; and who use their brain and their heart, not a horde of consultants, to manage their patients.

And these are the teachers who don’t order expensive, state-of-the-art studies when cheaper, conventional tests supply the same information; who don’t administer a slew of medications in an effort to alleviate every possible ill; who appreciate that doing nothing is, at times, doing a lot; and who realize that many people get well despite what we do, not because of what we do.

Unfortunately, these necessary role models are a vanishing species. Most of them have died or retired, and those who still have regular contact with medical students and house officers are too few to stem the tide of technologic tenesmus.¹⁴

From age 37 to 87, he ran 253,010 miles, a current world record. One day in 1984, he ran 117 miles; one week in 1986, he ran 258 miles, 50.1 miles each day; one month he ran 761 miles, 24.5 miles per day; and 1 year (1982), he ran 7661 miles, or 21 miles per day. Dr. Fred, of course, kept a daily log throughout his running career. He recorded the number of runs per day, the distances covered, and variables such as weather conditions, bodily aches and pains, shoe problems, etc. The quarter of a million miles that Dr. Fred ran is >10 times the circumference of the Earth (24,901 miles) and greater than the maximum distance between Earth and the moon (252,700 miles).

His 88 boxes of papers are divided into several categories: biographical notes, administrative information, medical life, running life, family life, religious life, and legal cases. He was a fascinating man of wide interests and a dedicated physician.

William Clifford Roberts, MD
August 6, 2019