Guenter B. Risse




June 1, 2016

QUESTION: What inspired you to write the book and what is the focal point of the story?

ANSWER: I basically see myself as a storyteller. Throughout my academic career, I hesitated to operate in the often-treacherous swamps of excessive scholarly abstraction where a few chosen live, wrestle, and argue. Instead, influenced by current health-related concerns or events, I tend to search for their historical antecedents, delving into issues, institutions, and persons that could provide valuable context and meaning. This detective work requires imagination, diligence, and endurance sifting through old documentation and exploring the complexities of yesteryear mysteries. The results can be exciting: new facts and interpretations emerge, erased memories recovered, all turning over old beliefs and judgments.

After coming to SF in 1985, I was intrigued about the untimely death of a Chinese laborer, nicknamed “Chick Gin” who died from bubonic plague in San Francisco’s Chinatown in 1900. This fascinating topic had already inspired several scholarly and popular publications but authors had neglected to explore in depth the feelings and reactions of the community directly afflicted by the plague. For this purpose and with a grant from the National Library of Medicine, I started a new project in 2007. Aided by a team of Chinese translators, the long suppressed voices represented in the Chung Sai Yat Po or Chinese Western Daily allowed for a much more insightful and balanced account. Plague in Chinatown and the fate of Wong Chut King, however, turned out to be merely a late chapter in a long California saga of fear and discrimination that began half a century earlier, centered around the creation of an isolation facility that came to host victims of other stigmatized contagious diseases, predominantly Chinese. After completion of the book Plague, Fear, and Politics in San Francisco’s Chinatown in 2012, therefore, I set out to trace the evolution of the city’s pest house. Here again, it was the tragic story of a former Chinese prostitute, Ah Lee, nicknamed “China Annie” that anchored my research. Perhaps in hindsight the opposite sequence would have seemed more logical, but Wong was already famous while Annie was still buried in a medical report on leprosy tangential to an institution virtually erased from San Francisco’s memory. Yet good detective work seldom disappoints. Working almost exclusively with small bits of data buried in newspapers, the onerous task of putting together the pieces of this pest house puzzle was tedious and time-consuming. Without the previous background this would have been nearly impossible.

We all know that the state is traditionally responsible for public safety and must protect the population’s wellbeing, notably from an onslaught of epidemic disease. To achieve this goal, the authorities frame disease as an enemy and thus implement stringent and often aggressive public health measures of detention and isolation that today appear unduly punitive and dehumanizing. The story of the SF Pesthouse, therefore, with all its grim details should be considered a powerful cautionary tale about our need to tame our evolutionary survival instincts, fear, aggression, and especially in America xenophobia and racism. Yet, confronted with new and often exotic infectious diseases, notably avian flu, SARS, Ebola, and now zika fever, a national sense of vulnerability prompts calls for military intervention and even martial law. We should balance the common good and preserve a modicum of individual liberty if we want to be successful in stemming future outbreaks.


QUESTION: What was the San Francisco Pesthouse?

ANSWER: So-called “pest houses” or lazarettos were historically temporary facilities created in urban centers. Their mission was to segregate and isolate individuals suspected or actually suffering from diseases deemed contagious and therefore capable of igniting an epidemic outbreak. This measure was primarily seen as preventative: to spare the healthy majority. Detention proceedings were expected to last for the duration of an epidemic threat. Segregated individuals were given the chance to rest, be attended, and possibly recover. However, given the serious nature of the infections and dearth of caregivers, many inmates came to perish in these institutions, a fate that led to their reputation as terrifying places of suffering and death.

Initially conceived during the Black Death pandemic in Europe, lazarettos and quarantine stations were preferably located at critical entry points for people and goods: port cities or if available, nearby, secluded islands. Throughout its history, the San Francisco Pesthouse was considered the most reviled institution in the city. Referred by contemporaries as a “den of horrors,” it opened its doors after the Gold Rush for the coercive isolation of arriving migrants-- notably Chinese—suspected of suffering from contagious diseases. Anticipating a cholera epidemic in 1850, San Francisco quickly built its first pest house, a temporary shack on Broadway, later transferred to Rincon Hill and Yerba Buena. Given the escalating dangers of mass infection and the always popular not in my backyard placement, the choice of location by 1860 became a hillside in then largely rural Potrero Nuevo (new pasture) neighborhood, at the intersection of 26th and De Haro Streets, a desolated promontory but one of the sunniest spots on the entire peninsula. To discourage visitors, the faraway cabin was difficult to reach from the city. The journey took place over a grid of narrow, poorly graded dirt roads built during the Gold Rush days, winding across the hill and forcing horses to stumble and halt at every step.

The secluded five-acre site faced the mouth of Precitas Creek, a small stream flowing into the Islais inlet of San Francisco Bay. The bucolic setting overlooked marshland and was exposed to westerly breezes capable of sweeping away any potential contagious vapors said to escape from the fever-stricken sick. To neutralize and prevent the dispersal of such pernicious bodily stench, a barrier of aromatic eucalyptus trees were planted to shield the surrounding countryside.

Here on a hillside overlooking the Bay the Pesthouse remained for almost a century, until its final closure in 1923. This occurred in spite of subsequent urban sprawl and numerous protests from anxious neighbors who seemingly feared for their lives. The SF Pesthouse uniqueness stems from the fact that beyond harboring infected people to prevent major outbreaks, the institution experienced significant mission creep. Indeed, nearly from the start, the establishment became a convenient instrument for blatant racial segregation, confining not only Chinese suffering from syphilis and leprosy, but also warehousing within its walls a host of other terminal patients burdened with a variety of chronic ailments like paralyses and blindness.


QUESTION: Why should we focus on emotions in framing this story?

ANSWER: Emotions are essential forms of human experience. Based on specific cultural values and collective aims, feelings become instruments of human communication and survival. However triggered, feelings are not trivial, they have profound consequences. They determine and shape responses and actions that must be properly understood and respected. Basic and contingent states such as fear, anger, disgust, guilt, and shame organize human life and society. With the help of disciplines like cognitive neurobiology, anthropology, as well as evolutionary, social, and clinical psychology, new insights are emerging concerning a broad range of sentiments and their influence on human beliefs and decision-making.

Self-preservation is intuitive; emotion-driven behavior routinely responds to perceived risks. Indeed, since ancient times, aversive sentiments have decisively contributed to the identification of epidemic threats, making possible their evasion or control. Any diseased person can become a menace, turning into a undesirable and dangerous ’other.” Feelings of avoidance are generated and expressed within particular social contexts shaped by biological, cultural, as well as political and economic factors. While the biological substrate of emotional responses is more or less the same, time, place, culture, and societal circumstances, as well as levels of scientific knowledge and the shifting ecology of disease, all determine their expression. Guided by the memory of previous vivid emergencies, new experiences can lead to notoriously flawed and often skewed “gut” reactions. These emotions influence the brain’s slower, conscious, and reflective rational network, particularly if they are fabricated or manipulated by particular ideologies or political and economic interests. Indeed, excessive and unreasonable emotional experiences have played an important role in human history, leading to hasty and notoriously biased responses in a hazardous world of crises, disasters, and pandemics.

Regardless of precise anatomical location, human emotions deserve to be explored more fully and inform the past. Once upon a time, history prided itself on its perceived objectivity. Scholars aiming for strict impartiality were reluctant to focus on and analyze sentiments in their reconstructions. Now, however, the discipline is expanding its boundaries. It attempts to interpret and analyze the prevailing emotional webs prevailing in previous societies. Bounded by culture, geography, and time, narratives endeavor to explain why and how we collectively or individually expressed our feelings. History in now asking: what role do emotions played in organizing thought, conduct, and social relationships? When unleashed, what was their impact?

From an evolutionary point of view the emotional processing system is much older and not quite as accessible to conscious awareness and control. In most instances, emotions seem to operate as an early warning system, monitoring and detecting environmental dangers, physical or social threats based on prior experiences. They provide quick appraisals and protective responses meant to be beneficial for human survival.


QUESTION: Why do we focus so much on fear and disgust?

ANSWER: “Visceral” or “gut reactions” monitor, inform, and influence the brain’s slower, conscious, and reflective rational networks charged with organizing and modulating this information based on normative models of thought. In response to evolving social and cultural norms, a blend of negative feelings such as dread and repulsion surface to confront potential dangers that have gradually expanded to include aesthetic and moral judgments. Feelings of rejection and hostility are important building blocks for constructing stigma and creating stereotypes. While gruesome visual images provide physical, aesthetic and moral appraisals, smell and touch offer their own impressions and language to bolster aversive emotions. Such sensory cues trigger or enhance fear and repugnance.

The visible horrors of bodily infection and corruption both trigger fright and withdrawal. In this highly emotional context, sensory and social avoidance techniques designed to keep sick and bad smelling people at bay came to rein supreme, enabling individuals and communities to avoid similar contamination and possible death. The task began with detection of prominent symptoms and signs of disease with the help of visual, odoriferous, tactile, and auditory sensations. Accounts of illness in family, friends, or society at large all also contributed to the experience. Proximity and personal recollections heightened contempt; avoidance of similar situations became routine. Memory of past epidemic disasters, coupled with plausible predictions regarding future crises, had lasting effects on human behavior over the course of millennia.

Since its inception, people in the United States have displayed a singular emotional style: strong fear of contracting diseases brought to its shores by immigrants streaming from all over the world. In fact, dread has recently been called “one of the dominant emotions in contemporary American public life.” According to the modern Western sanitary gospel, the newly arrived “unwashed” were expected to adopt hygienic values on their road to assimilation and eventual citizenship. By the end of the summer 2009, as fears of a lethal and catastrophic pandemic of H1N1 influenza outbreak escalated, Fox News aired a television segment with flashing signs of “Mass Quarantines” and a repetitive sound track declaring “Be Very Afraid.”

California’s emotional landscape was shaped by environmental and cultural factors linked to the consequences of Gold Rush. Self-reliance, independence, and the pursuit of personal wealth favored narcissism and discouraged social cohesion. Distrust of government led to weak and corrupt political, administrative, and legal institutions. In a world of intense social and economic competition requiring a great deal of physical and spiritual stamina, health and illness were mostly private concerns. Such a mindset in San Francisco led to an underfinanced municipal health department. Threats to individual wellbeing lurked everywhere, sparking distress and fear regarding implications for employment and survival. Often deprived of aid provided by family and friends, vulnerable newcomers easily panicked, went into hiding, blaming and lashing out at strangers.


QUESTION: Why are we so disgusted?

ANSWER: Today humanity is said to be a visceral, disgust-obsessed species. Globalization and the formation of pluralistic societies seem to have only enhanced feelings of fear, distaste, and revulsion that cover virtually all aspects of human relationships. Disagreeable feelings are facially expressed through a wrinkled nose, raised lips, and open mouth, often followed by the squeezing of the throat and nausea. This suggests that, in an evolutionary context, disgust was originally activated to protect us from orally transmitted threats, primarily the intake of unsuitable nourishment capable of triggering vomiting and diarrhea. In fact, the term “disgust”—literally, “bad taste”— refers specifically to spoiled and harmful foodstuffs, their detection, and avoidance to prevent serious gastrointestinal effects. Perhaps this “grossed out” or “yuck” feeling intensified among early agricultural and pastoral societies that exposed humans to greater health hazards. In an unfamiliar world of nourishment prone to decay, disgust served as a protective measure, establishing rules and taboos concerned with food preparation and consumption.

Beyond digestive avoidance, expressions of revulsion meshed with threats to bodily balances. Sweat, saliva, stool, semen, decaying corpses, and deadly diseases made disgust the body’s guardian. Provided with a host of new cues from sensory perceptions, humans withdrew and distanced themselves from a variety of disagreeable agents: spoiled foodstuffs, garbage, bodily fluids, dirt and wastes, as well as sewage.

Expansion of human populations multiplied the frequency and intensity of interpersonal contacts. Activated by novel sights, smells, and potential contaminants, emotions of dread and defilement came to shape and regulate social interactions. In fact, disgust has been coined the emotion of civilization, a key mechanism for setting specific physical and moral boundaries and guarding us against a widening spectrum of perceived threats. Strangers or unfamiliar “others”—came to be shunned or rejected. Individual and social prejudice as well as stereotyping morphed into powerful tools for constructing ideologies of nativism, race, and class shaping political discourse and action. Divisions based on morality, ethnicity and nationality joined others based on religious beliefs and gender roles. Minorities were stigmatized, inequality justified, violators punished.

Triggered by accelerated urbanization in late medieval and early modern Europe, the sanitary concept—filthy and spoiled environments breed poisons capable of causing diseases—became a key Western cultural formulation based on more frequent encounters with deadly epidemic disease. Clearing away rubbish and excrement from narrow, unpaved streets, opening drains, and cesspools and installing latrines in crowded cities, began as emotional imperatives. Later, nineteenth-century public health policies drew on a powerful rhetoric employing strong code words such as “filth” and “stink,” exacerbating potent feelings of revulsion and fear of contamination, especially in industrial urban Europe and America. Remembrance stoked individual and communal imaginations to fashion a rationale for establishing quarantines and pest houses, domains of disgust representing physical and moral gatekeeping.


QUESTION: Who populated the Pesthouse?

ANSWER: With the Gold Rush, migration, notably from Asia, gained momentum. Every ship brought hundreds of Chinese to America’s shores, some of them already suffering from “loathsome” diseases. The use of this code word was deliberate; it was part of an emotional vocabulary designed to instill aversion. Loathsomeness implied a broad range of revolting feelings, from outright physical repulsion to moral contempt, fear to outrage, odium to horror. Primarily intended to identify acute infectious cases with hideous skin manifestations, the attribution was also linked to cultural biases and presumed ethical infringements. Prominent among the “loathsome” diseases requiring removal were cases of smallpox, advanced stages of syphilis, leprosy, and plague, joined occasionally by disfiguring forms of cancer and crippling paralyses. Because of their overlapping symptoms and imprecise, shifting nomenclature, such contemptible conditions continued to be mired in clinical confusion and diagnostic quandaries.

Smallpox was a regular San Francisco visitor, transforming the Pesthouse into an overcrowded and understaffed facility dealing exclusively with patients suffering from the disease. Mostly young, poor and unattached, its victims struggled in stuffy rooms, hoping to recover in spite of minimal care. The influx of Chinese sufferers of the disease necessitated a segregated facility, an annex. Dubbed the “China House,” it soon became the destination of other undesirable Asiatic patients with syphilis and leprosy. Their transfer from the municipal hospital avoided potential institutional revolts led by racist white inmates and caregivers.

Persistent budgetary neglect allowed buildings to crumble, staff to quit, and scarce supplies. An inspection tour of the institution in 1892 unnerved the current Health Board members. They pronounced the place “a disgrace to a wealthy city like San Francisco,” accusing Supervisors of “neglect of duty.” By this time, the decrepit facilities had joined San Francisco’s “putrid row”, a corridor populated by slaughterhouses and other polluting industries along the Bay shore from Butchertown to Hunters Point. The once pristine inlet became an outlet for various sewers. Lack of garbage removal services amplified the stench emanating from the adjacent marsh known as “hell broth.”

Courtesy of the “penuriousness of the municipality”, the buildings—old recycled voting booths--resembled dog kennels. Walls spotted large holes plugged with cans and old shirts to protect from drafts. The atrocious scene was one of utter desolation and decay. Space strongly influences emotions, but a lack of sources makes it difficult to speculate about how the patients dealt with their situation at the personal and social level. In drawings, inmates, scantily clad in old rags, simply seemed to stare into space, suggesting that depression and hopelessness were ubiquitous. We know that a few escaped; others committed suicide.

At the outset, local physicians knew very little about leprosy. References to the Scriptures were common. When checking for scabs among Chinese, the SF Health Officer was observed consulting the Bible. Faced with a steady arrival, the authorities with police escorts forcefully marched many of them to the harbor for a paid return trip to China.

After the embarrassing Pesthouse visit, an appeal went out through the newspapers for private donations of food and wine, tobacco, clothing and shoes, as well as playing cards, all timed for the Christmas holidays. At the traditional Christmas dinner in 1902, the inmates were finally able to share new clothes, books, and an assortment of fruits and candies with another female inmate. Sacks of rice, sweet potatoes, and a suckling pig roasted in oriental style provided for at least one happy meal.


QUESTION: What is your favorite story?

ANSWER: The bittersweet account of Ah Lee variously called “Annie,” or “China Annie,” offers one of the few glimpses of life as a pariah in a hideous institution. Her case was emblematic: she turned out to be the most stigmatized person ever to enter the San Francisco Pesthouse. The 29 year old was admitted to the annex on April 10, 1891. She admittedly came from the small village of Sun Ning belonging to the Four Districts region west of the Pearl River Delta in Guandong Province. Kidnapped at age 15 during a raid by foreign invaders, she ended up in Hong Kong, sold into slavery and brought to California for purposes of prostitution. After a six-month seasoning in San Francisco, Annie was transported to Salt Lake City where at age 22, she contracted and survived a case of smallpox. Like many of her sisters, Annie by 1886 started to display skin eruptions promptly ascribed to syphilis, always a career-ending hazard. Having bought herself free from her prostitution contract because of the venereal ailment, she managed to find a cook working in a mining camp near Salt Lake City who agreed to marry her despite her condition. Two years later, however, Annie detected facial discolorations and swellings around nose and scalp, together with nodules on the surface of her right hand and arm that were suspicious of leprosy. Confronted by her progressive disabilities, she decided to return to San Francisco in early 1891. If her intent was to seek admission to the Pesthouse, she was successful: the diagnosis confirmed by the City Physician. Surrounded by an exclusively male population, Annie agreed to perform a number of housekeeping chores, earning a few pennies for her trouble and getting her own little room. Clad in rags and wearing broken shoes, she shuffled around, covered head to toe with the remnants of a gifted white scarf.

Like most leprous inmates, Annie’s condition steadily deteriorated. According to an 1894 report, the whole face with its sunken nose appeared grotesque, swollen with numerous anesthetic infiltrates and scaring from previous ulcers. By now she was partially bald, lacking eyebrows or eyelashes. Both arms displayed similar lesions. In spite of chalmoogra oil injections, her right hand remained contracted. In the summer of 1896, Annie demanded to be included in a privately financed trial with a Japanese herbal. Surprisingly, the daily baths and pills helped her temporarily recover some strength and resume laundry work.

Staff members often referred to Annie as “the musical girl.” Visitors recalled that her music provided amusement and consolation to other inmates. Based on press reports, Annie cheerfully played a small organ popular after the 1880s: the organette equipped with paper music rolls perforated for specific songs, including religious and sentimental ballads. Annie seemed to keep in touch with the most popular melodies of the day. They included James Thornton’s popular 1890s ballad My Sweetheart’s the Man in the Moon and, surprisingly, Charles S. O’Brien’s Ma Angeline, a so-called coon song stereotyping blacks.

One last reference to “old and blind China Annie” came during the Christmas festivities of 1904. Reports suggest that she diedthe following year. In spite of her long history of degradation and suffering, Annie’s 14 years in exile eloquently displayed the triumph of the human spirit. The lyrics of one popular song, The Little Old Log Cabin in the Lane, offered an eerie vision of Annie’s current predicament. The lyrics spoke of a decrepit cabin with a caved, leaky roof surrounded by decaying fences and a dry creek. Most poignant is the song’s last refrain: “Well, I ain’t got long to stay here, and what little time I’ve got I’ll try to rest content while I remain, till death shall call this dog and me to find a better home than the little old log cabin in the lane.”


QUESTION: What should readers take away from this book? Are there lessons to be learned?

ANSWER: Historically, suspects or sufferers of “loathsome” diseases were expected to cope and adjust to their stigmatized status as pariahs. Medieval castaways were forced to dispose of their properties and leave homes and communities. Shamefully concealing their disgusting appearances, suspects and sufferers were often forced to abandon occupations, break up relationships, seek admission to special institutions, or simply go into hiding. Yet coercion always compromises human dignity, a complex religious and secular concept closely linked to identity and social status. The crass inhumanity of such an exile was obvious.

With the advent of civil rights, so-called “social distancing” in private homes or hospital seclusion are now seldom involuntary. Yet, the psychological effects of strict isolation can be serious. Anxiety and fear of contagion--even the possibility of death--can leave many suspects traumatized, lonely, and depressed. In SARS, some observers claimed that, following their ordeal, quarantined persons suffered from post-traumatic stress disorder.

Current epidemic threats such as AIDS, SARS, avian influenza, and the health consequences of natural disasters such as floods and earthquakes, even bioterrorism, challenge our public health policies and procedures. Near panic, a majority of the public demand visible and muscular responses. A national poll suggested that over 80% of the population favored stringent measures to deal with the Ebola fever outbreak. Several governors--some engulfed in reelection campaigns—obliged “out of an abundance of caution,” ordering strict and mandatory 21-day home quarantines. The seclusion targeted all health care workers returning from West Africa after an emotionally draining tour of duty attending Ebola patients. Tracked by police, the potentially infected were to monitor their temperature but were not allowed to contact family members or receive visitors. Humans have always framed their reaction to the presence of disease by employing military metaphors.

Because mass disease posed an existential risk, police or military personnel engage in coercive responses powered by aversive emotions. According to the Centers for Disease Control and Prevention, quarantine and isolation are still considered effective “police power” functions designed “to protect the public by preventing exposure to infected persons or to persons who may be infected. In emergencies, the Department of Defense plays an important role in mobilizing troops while state, local, and tribal law continues to guide the implementation of similar protective measures to control the spread of infectious disease within their jurisdictions. After the Ebola outbreak, a presidential executive order urged the Defense Department to prepare for a call up of reservists from the National Guard, and set up a rapid reaction squad. The so-called “Ebola SWAT team” was envisioned as a specialized group of experts in logistics, epidemiology, medicine, and specialized caregiving, assembled by the CDC and ready for deployment anywhere in the US to assist local authorities and healthcare systems in safety and infection control.

Yet, suspicion and apprehension about militarized federal interventions linger, notably in an American culture proud of its organizational prowess and “can do” resolve. Detention can often be counterproductive; humiliating and degrading violations of human dignity frequently tend to encourage resistance and evasion. Like their predecessors centuries ago, contemporary public health authorities dealing with Ebola admitted that aggressive monitoring and watching can trigger “perverse incentives” to evade the quarantine.

Both the trajectory of the San Francisco Pesthouse as well as the 1900 outbreak of bubonic plague in San Francisco’s Chinatown provide windows into sad but instructive episodes in West Coast and American history. If not the voices and emotions then certainly the fate of those who suffered discrimination and disease must be uncovered. The lessons for today are that top-down authoritarian measures—even those grounded in the latest scientific insights--will fail without the uncoerced participation of the afflicted communities. If we are to learn from history, we must understand the prejudices and social dynamics of populations affected by these scourges in order to devise policies and coordinated procedures that are just and fair for all. Everyone, not only the authorities and medical profession, have a stake in public health measures. Cooperation instead of confrontation with those at risk is essential if the efforts to contain disease are to bring success.