The study of epidemics has routinely centered around what medical historian Charles Rosenberg calls a “dramaturgic structure”: a story of infection that builds to a climax of widespread illness and woe, and then comes to a definitive end. The ongoing COVID-19 pandemic has defied this structure, failing to come to a complete stop. But this is not the first time in history that the social and cultural impacts of an epidemic have continued past the time that the state and much of society declare that it is over. Epidemics often live far beyond their supposed ends. My research into 19th-century cholera epidemics in Argentina’s northwestern province of Tucumán shows that epidemics don’t have a single, definitive end, but instead two incomplete ones: the celebrated end when an authority declares the outbreak over, and the muted end brought about by gradual loss of interest.

Three cholera epidemics befell Tucumán in the 19th century, in 1867-68, in 1886-87, and in 1894-95. Each time, the bacterium vibrio cholerae, which causes the disease, arrived in the province through trade and migration. During the 19th century, new railroad lines connected the populous coast with the nation’s interior, radically transforming Tucumán, a place where social, economic, and political life was dictated by sugarcane cultivation and refining. The new train lines allowed the sugar industry to import improved machinery and to attract workers for the yearly harvest. They also brought new diseases to the province, where endemic malaria and occasional bouts of measles and smallpox had already taken hold. Cholera was one of these new illnesses. The gastrointestinal disease benefited from the lack of plumbing in the 19th century that moved human waste in a sanitary and efficient manner. As a result, urban and confined spaces were prime areas for outbreaks.

In Argentina, cholera first landed at the bustling ports of Buenos Aires aboard many of the ships that arrived daily to transport people and goods. Global trade routes facilitated cholera’s transit from the waters of the Indian Ocean, its point of origin, to Argentina. Once there, it moved over the country’s new rail lines to the interior provinces.

Cholera spread through trade and migration routes. Courtesy of Wellcome Collection.

The first two cholera epidemics paralyzed Tucumán’s economy and society—especially the sugar industry that dominated all areas of the social fabric, and that provided elites with the foundation for their political and economic power. As news reached Tucumán of a possible outbreak, officials mustered resources to prepare. They transformed two rail stations into sanitary stations to inspect and fumigate goods and travelers arriving in the province. Doctors prepared labs to inspect bodily fluids for vibrio cholerae, to confirm disease and enforce isolation practices. Cholera particularly impacted the popular classes, who lived in makeshift homes built from found materials, with multiple families sharing the space. Many businesses closed, either from their own decision or because workers were staying home out of fears of contracting the disease. The affluent retreated to their private homes in the mountains, both as a form of social distancing and under the belief that higher altitude was salubrious.

The epidemics also created national political turmoil. In 1887, a mob in the southern countryside rose up against and killed volunteer Spanish Red Cross workers from Buenos Aires, believing free medications were laced with poison. From there, the mob moved throughout the countryside in search of other Red Cross workers. The event became national news, with sectors of the press considering the attack an act of xenophobia. The national government used the attack—and the supposed general mishandling of the epidemic in Tucumán—as a pretext to remove the local government.

On November 6, 1894, as summer approached in Argentina, the Tucumán newspaper El Orden reported that the province was “entering the season of the year in which the warm temperature is ideal for epidemics.” The editors urged the local government to enforce preventative measures, calling for street cleaning, for draining the pools of stagnant water that collected during the rainy summer, and for the province’s small cadre of health officials to monitor the living conditions of the popular classes.

The paper reported on the situation throughout the summer. Suspected cases of cholera appeared by the end of November, but through February of 1895 there was nothing concrete. Then, in March, cases erupted. El Orden reported, for instance, that one man abandoned his sick wife, María Gutiérrez, in front of the sole hospital in the provincial capital, San Miguel. Gutiérrez is one of the few cholera victims recorded by name; in other instances, the newspaper simply wrote about illnesses of “a man on the 1000 block of San Juan Avenue” or “20 cases in the town of San Felipe.”

Despite the newspaper’s careful record of the epidemic, however, official government documents reported no cholera epidemic in Tucumán in 1894-95. The province’s governor gave an annual address declaring early preventative measures a resounding success. He applauded the provincial Hygiene Commission for coming in under budget on a program to disinfect all people, goods, and things entering Tucumán along railway lines, and even went so far as to suggest that public health conditions in Tucumán had improved.

Authorities and local journalists had completely different interpretations of the epidemic. Perhaps fearing a repeat of 1887, the government rushed to declare the 1894 outbreak over before it had even begun.

In my research, I used El Orden, one of the only sources documenting the 1894-95 epidemic, to track how the muted end of the epidemic—the flipside of the provincial government’s declaration that the outbreak had never even begun—unfolded. I searched the papers for articles reporting deaths. While the newspaper at first vigilantly documented the epidemic, with cholera dominating its front pages, after a few weeks, its reporting on new cases and deaths became less frequent. Eventually, new cases and deaths were relegated to the back pages, alongside business advertisements and classifieds.

The last cases reported by the newspaper noted 10 peons dying at the mill of industrialist-politician Wenceslao Posse, three at the General Hospital of San Miguel, and many more cases in the immediate countryside of San Miguel. From there, discussions of the epidemic evolved into more general concerns about the continued growth of the province’s population and worries over a proliferation of shantytowns, few paved streets, limited potable water access, and having one of the nation’s highest infant mortality rates. The public slowly lost interest in cholera, even as deaths continued, evidenced by sporadic mentions buried in the pages of El Orden.

The epidemic’s slow fade-out came from simple fatigue: Actors across the social spectrum were tired of working to prevent the disease, and balked when preventative measures created economic costs. Put another way, for both the celebrated and muted ends, the epidemic ended when the market and public health could not work in sync. The points of reckoning just came at different times for different sectors of society.

Much of the same is seen in the current pandemic, whose endpoint has been anything but clear. As the U.S. Centers for Disease Control and Prevention and municipalities relax guidelines regarding quarantine and masking, arguing that COVID has reached a state of endemicity, others reject the idea of ending public health interventions and resigning ourselves to a future of regular outbreaks. Still others argue that the end of the epidemic does not come from lifting restrictions, but from reinforcing measures that protect the vulnerable sections of society, like the immunocompromised, those with vulnerable conditions, and the elderly.

The process of calling an end to the current pandemic is difficult and uncertain. One lesson from Tucumán is that it is likely not up to us to declare the end of COVID, but to future generations who will look back and see through the contradictions we leave in our historical material.

The post How Do Pandemics End? appeared first on Zócalo Public Square.

On July 10, 1520, Aztec forces vanquished the Spanish conquistador Hernán Cortés and his men, driving them from Tenochtitlan, capital of the Aztec empire. The Spanish soldiers were wounded and killed as they fled, trying in vain to drag stolen gold and jewels with them.

The Spanish more than deserved the routing they got, and the conflict should have ended then. But a fateful surprise made those losses insignificant. By September, an unexpected ally of the would-be conquerors had reached the city: the variola virus, which causes smallpox.

How the Aztecs responded to this threat would prove critical.

The Aztecs were no strangers to plagues. Among the speeches recorded in their rhetoric and moral philosophy, we find a warning to new kings concerning their divinely ordained role in the event of contagion:

Sickness will arrive during your time. How will it be when the city becomes, is made, a place of desolation? Just how will it be when everything lies in darkness, despair? You will also go rushing to your death right then and there. In an instant, you will be over.

Facing a plague, it was vital that the king respond with grace. They warned:

Do not be a fool. Do not rush your words, do not interrupt or confuse people. Instead find, grasp, arrive at the truth. Make no one weep. Cause no sadness. Injure no one. Do not show rage or frighten folks. Do not create a scandal or speak with vanity. Do not ridicule. For vain words and mockery are no longer your office. Never, of your own will, make yourself less, diminished. Bring no scorn upon the nation, its leadership, the government.

Retract your teeth and claws. Gladden your people. Unite them, humor them, please them. Make your nation happy. Help each find their proper place. That way you’ll be esteemed, renowned. And when our Lord extinguishes you, the old ones will weep and sigh.

If a king did not follow this advice, if his rule caused more suffering than it abated, then the people prayed to Tezcatlipoca for any number of consequences, including his death:

May he be made an example of. Let him receive some reprimand, whatever you choose. Perhaps punishment. Disease. Perhaps you’ll let your honor and glory fall to another of your friends, those who weep in sorrow now. For they do exist. They live. You have no want of friends. They are sighing before you, humble. Choose one of them.

Perhaps he [the bad ruler] will experience what the common folk do: suffering, anguish, lack of food and clothing. And perhaps you will give him the greatest punishments: paralysis, blindness, rotting infection.

Or will he instead soon depart this world? Will you bring about his death? Will he get to know our future home, the place with no exits, no smoke holes? Maybe he will meet the Lord of Death, Mictlanteuctli, mother and father of us all.

Clearly, the Aztecs took the responsibilities of leadership very seriously. Beyond uplifting morale, a king’s principal duty in times of contagion was deploying his subjects to “their proper place” so that the kingdom could continue to function. This included mobilizing the titicih, doctor-healers with vast herbal knowledge, most of them women pledged to the primal mother goddess Teteoh Innan.

What about the rest of the people? As with our own modern call for “thoughts and prayers,” the Aztecs believed their principal collective tool for fending off epidemics was a humble appeal to Tezcatlipoca. The very first speech of their text of rhetoric and moral philosophy was a supplication to destroy plague. After admitting how much they might deserve this scourge and recognizing the divine right of Tezcatlipoca to punish them however he sees fit, the desperate Aztecs tried to get their powerful god to consider the worst-case outcome of his vengeance:

O Master, how in truth can your heart desire this? How can you wish it? Have you abandoned your subjects? Is this all? Is this how it is now? Will the common folk just go away, be destroyed? Will the governed perish? Will emptiness and darkness prevail? Will your cities become choked with trees and vines, filled with fallen stones? Will the pyramids in your sacred places crumble to the ground?

Will your anger never be reversed? Will you look no more upon the common folk? For—ah!—this plague is destroying them! Darkness has fallen! Let this be enough. Stop amusing yourself, O Master, O Lord. Let the earth be at rest! I fall before you. I throw myself before you, casting myself into the place from which no one rises, the place of terror and fear, crying out: O Master, perform your office … do your job!

How many times was this prayer repeated as smallpox ate its cruel way into Mexico, as the domain of the Mexica—ruling people of the Aztec empire—was then already called? We know prayer and the skills and knowledge of the healers were no match for the novel virus.

Smallpox arrived in Mesoamerica with a second wave of Spaniards who joined forces with Cortés. According to one account, they had with them an enslaved African man known as Francisco Eguía, who was suffering from smallpox. He, like many others on the continent of his birth, had no immunity to the disease carried there by the slave traders.

Eguía died in the care of Totonac people near Veracruz, the port city established by the Spanish some 250 miles east of the Aztec capital. His caretakers became infected. Smallpox spreads easily: not only blood and saliva, but also skin-to-skin contact (handshakes, hugs) and airborne respiratory droplets. It raced through a population with no herd immunity at all: along the coast, over the mountains, across the waters of Lake Texcoco, into the very heart of the populous empire.

The epidemic lasted 70 days in the city of Tenochtitlan. It killed 40 percent of the inhabitants, including the emperor, Cuitlahuac. Had he found it increasingly difficult to keep his people’s spirits up as tradition commanded? Had his leadership faltered? Did his subjects pray for his death?

Whatever the case, the memory of that devastation would echo for centuries. Some Nahuas—mostly the sons and grandsons of Aztec nobility—described the devastation decades after the conquest.

Their account harrows the soul:

It started during Tepeilhuitl [the 13th month of the solar calendar], when a vast human devastation spread over everyone. Some were covered in pustules, which spread everywhere, on people’s faces, heads, chests, etc. There was great loss of life; many people died of it.

They could not walk anymore. They just lay in bed in their homes. They could not move anymore, could not shift themselves, could not sit up or stretch out on their sides. They could not lay flat on their backs or even face down. If they even stirred, they screamed out in pain.

Many died of hunger, too. They starved because no one was left to care for the others; no one could attend to anyone else. On some people, the pustules were few and far between. They caused little discomfort, and those folks did not die. Still others had their faces marred.

By Panquetzaliztli [the 15th month of the solar year], it began to fade. At that time the brave warriors of the Mexica managed to recover.

But a hard lesson had been learned. None of the old remedies had worked. Entire families were gone. Funeral pyres effaced the sun. Although Tezcatlipoca may have heeded their supplications at the end, the price he had made his people pay was staggering.

The epidemic was only the beginning of the unexpected forces working in tandem to bring down the Aztec empire. On May 22, 1521—just as Tenochtitlan was beginning to recover, trying to rebuild trade routes, restock its supplies, replant its fields and aquatic chinampa gardens—Cortés returned.

This time he commanded more Spanish troops, men from the same second wave that had brought the smallpox. With them marched tens of thousands of Tlaxcaltecah warriors, the sworn enemies of the Aztecs. Smallpox had reached Tlaxcallan first, but its people—not as densely packed in urban areas like the Mexica—had fared better and were now ready to finish off their rivals.

The massive military force laid siege to the Aztec capital. Even with more than half the population dead or disabled, with little food or water or supplies, the Mexica held the city for three months.

Then, on August 13, 1521, it fell. Emptiness and darkness indeed prevailed.

Lines from a song composed by an unknown Mexica not long afterward sums up the emotions of the survivors:

It is our God who brings down
His wrath, His awesome might
upon our heads.

So friends, weep at the realization—
we abandon the Mexica Way.
Now the water is bitter,
the food is bitter: that
is what the Giver of Life
has wrought.

Without the smallpox, it’s much less likely Cortés and his allies could have taken Tenochtitlan. The epidemic exposed the city’s weakness: the need to import essential goods along causeways that could be destroyed to cut the isle off from the world, the vulnerable aqueduct that carried the city’s only fresh water from distant Chapultepec Hill, the tightly packed boroughs in which commoners lived and worked. The Aztecs were brilliant engineers and soldiers, with capable titicih, but the old ways were not enough. No one thought to isolate the infected, to confine the healthy to their homes to keep them safe. And, absent the practice of inoculation discovered by Chinese physicians a few centuries earlier, there was no safer way of building herd immunity in Tenochtitlan.

Without innovative ways to slow it, smallpox helped invaders bring down an empire. That’s the power of novel viruses, proven time and again. We would do well to learn the lesson.

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With Knopf’s guidance, in the 1890s the New York City Health Department launched a massive campaign to educate the public and reduce transmission. The “War on Tuberculosis” public health campaign discouraged cup-sharing and prompted states to ban spitting inside public buildings and transit and on sidewalks and other outdoor spaces—instead encouraging the use of special spittoons, to be carefully cleaned on a regular basis. Before long, spitting in public spaces came to be considered uncouth, and swigging from shared bottles was frowned upon as well. These changes in public behavior helped successfully reduce the prevalence of tuberculosis.

A view of Broadway, in New York, in 1858. Nineteenth-century Manhattanites didn’t understand that actions like spitting in the streets and leaving horse waste out to rot contributed to high levels of disease. Courtesy of Wikimedia Commons.

As we are seeing with the coronavirus today, disease can profoundly impact a community—upending routines and rattling nerves as it spreads from person to person. But the effects of epidemics extend beyond the moments in which they occur. Disease can permanently alter society, and often for the best by creating better practices and habits. Crisis sparks action and response. Many infrastructure improvements and healthy behaviors we consider normal today are the result of past health campaigns that responded to devastating outbreaks. 

In the 19th century, city streets in the U.S. overflowed with filth. People tossed their discarded newspapers, food scraps, and other trash out their windows onto the streets below. The plentiful horses pulling streetcars and delivery carts contributed to the squalor, as each one dropped over a quart of urine and pounds of manure every day. When a horse died, it became a different kind of hazard. In “Portrait of an Unhealthy City,” Columbia University professor David Rosner writes that since horses are so heavy, when one died in New York City, “its carcass would be left to rot until it had disintegrated enough for someone to pick up the pieces. Children would play with dead horses lying on the streets.” More than 15,000 horse carcasses were collected and removed from New York streets in 1880. Human waste was a problem, too. Many people emptied chamber pots out their windows. Those in tenement housing did not have their own facilities, but had 25 to 30 people sharing a single outhouse. These privies frequently overflowed until workers known as “night soil men” arrived to haul away the dripping barrels of feces, only to dump them into the nearby harbor.

As civic and health leaders began to understand that the frequent outbreaks of tuberculosis, typhoid, and cholera that ravaged their cities were connected to the garbage, cities began setting up organized systems for disposing of human urine and feces. Improvements in technology helped the process along. Officials began introducing sand filtration and chlorination systems to clean up municipal water supplies. Indoor toilets were slow to catch on, due to cost, issues with controlling the stench, and the need for a plumbing system. Following Thomas Crapper’s improved model in 1891, water closets became popular, first among the wealthy, and then among the middle-class. Plumbing and sewage systems, paired with tenement house reform, helped remove excrement from the public streets.

Disease radically improved aspects of American culture, too. As physicians came to believe that good ventilation and fresh air could combat illness, builders started adding porches and windows to houses. Real estate investors used the trend to market migration to the West, prompting Eastern physicians to convince consumptives and their families to move thousands of miles from crowded, muggy Eastern cities to the dry air and sunshine in places like Los Angeles and Colorado Springs. The ploy was so influential that in 1872, approximately one-third of Colorado’s population had tuberculosis, having moved to the territory seeking better health.

Some of this sentiment continues today. While we know that sunshine doesn’t kill bacteria, good ventilation and time spent outside does benefit children and adults by promoting physical activity and improving spirits—and access to outdoor spaces and parks still entices homebuyers. This fresh-air “cure” also eventually incited the study of climate as a formal science, as people began to chart temperature, barometric pressure, and other weather patterns in hopes of identifying the “ideal” conditions for treating disease.

Epidemics of the past established an ethos of altruism in the U.S. During the 1793 yellow fever epidemic, Philadelphians selflessly stepped up to save their city. With no formal crisis plan, Mayor Matthew Clarkson turned to volunteers to collect clothing, food, and monetary donations; to pitch a makeshift hospital; and to build a home for 191 children temporarily or permanently orphaned by the epidemic. Members of the Free African Society, an institution run by and for the city’s black population, were particularly altruistic, providing two-thirds of the hospital staff, transporting and burying the dead, and performing numerous other medical tasks.

By the mid 20th century, public health experts began to think exposure to sunlight would ward off TB—and they promoted their theories through poster campaigns. Courtesy of the Library of Congress.

A 20th-century diphtheria outbreak in a small region in the Alaska Territory inspired a national rally of support—and created the Iditarod, the famous dog sled race. When cases of “the children’s disease” began to mount in Nome, Alaska, in January 1925, the town was in trouble. Diphtheria bacteria produces a toxin, making it especially deadly, unless the antitoxin serum is administered. This serum had been readily available for decades, but Nome’s supply had run short, and the town was inaccessible by road or sea in the winter. Leaping into action, 20 of the area’s finest dogsled teams and mushers carried a supply of the serum all the way from Fairbanks—674 miles—in record time, facing temperatures of more than 60 degrees below zero. Their delivery on February 2nd, plus a second shipment a week later, successfully halted the epidemic, saving Nome’s children from suffocation. Newspapers across the country covered the rescue. It was also memorialized in movies (including the animated Balto), with a Central Park statue—and, most notably, with the annual Iditarod race. The significant challenges of delivery by dogsled also sparked investigation into the possibilities of medical transport by airplane, which takes place all the time in remote areas today but was still in its infancy at the time.

Diseases fueled the growth of fundraising strategies. The polio epidemic of 1952 sickened more than 57,000 people across the United States, causing 21,269 cases of paralysis. The situation became so dire that at one point, the Sister Kenny Institute in Minneapolis, a premier polio treatment facility, temporarily ran out of cribs for babies with the disease. In response, the National Foundation of Infantile Paralysis (NFIP), which had been founded in 1938 by President Franklin D. Roosevelt and later came to be known as the March of Dimes, distributed around $25 million through its local chapters. It provided iron lungs, rocking chairs, beds, and other equipment to medical facilities, and assigned physicians, nurses, physical therapists, and medical social workers where they were needed. The March of Dimes success has served as the gold standard in public health education and fundraising since its heyday in the 1940s and 1950s.

Public health emergencies have inspired innovations in education. Starting in 1910, Thomas Edison’s lab, which had invented one of the first motion picture devices in the 1890s, partnered with anti-TB activists to produce short films on tuberculosis prevention and transmission—some of the first educational movies. Screened in public places in rural areas, the TB movies were also the first films—of any type—that viewers had ever seen. The anti-tuberculosis crusade was also a model for later NFIP efforts to combat polio that relentlessly put that disease at the front of public agenda until an effective vaccination was developed and implemented, and set a standard for future public health campaigns.

Past epidemics fueled the growth of civic debate and journalism in the U.S., too. As far back as colonial times, newspapers built their audiences by providing an outlet for debate on controversial issues, including disease. Founders of the New England Courant—the first paper in Colonial America to print the voices and perspectives of the colonists—launched their paper as a vehicle to oppose smallpox inoculation during the 1721 Boston epidemic. As smallpox ravaged the city, a Boston doctor named Zabdiel Boylston began using inoculation, a practice in which people are intentionally infected with a disease, to produce milder cases and reduce mortality risk. Backed by those opposed to the practice, James Franklin started the Courant to serve as a tool to fight it. Inoculation’s success was demonstrated in 1721 and later smallpox epidemics, eventually convincing even staunch opponents of its value—but by inspiring an outlet to air their concerns, the anti-inoculation camp had made an important contribution to public discourse.

Since colonial times, newspapers, pamphlets, and a host of other outlets have continued to thrive and evolve during outbreaks—updating the public on believed transmission and remedies, announcing store closing and quarantine restrictions, advertising outbreak-related job openings (florists, nurses, grave diggers, coffin makers, to name a few), and serving as spaces for public debate. The cycle continues today, as media powers and regular citizens flock to social media to discuss COVID-19—disseminating information, speculating on its origins, expressing fear of its unknowns.

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With the possible exception of opium during the Opium Wars, no drug has ever received a bigger stimulus from armed conflict. “World War II probably gave the greatest impetus to date to legal, medically-authorized as well as illicit black market abuse of these pills on a worldwide scale,” wrote Lester Grinspoon and Peter Hedblom in their classic 1975 study, The Speed Culture. Whether in the air or in the trenches, the war enabled the rapid proliferation of a synthetic stimulant that was particularly well-suited to sleepless work and intense concentration.

Amphetamines—often called “pep pills,” “go pills,” “uppers,” or “speed”—are a group of synthetic drugs that stimulate the central nervous system, reducing fatigue and appetite and increasing wakefulness and imparting a sense of well-being. Methamphetamine is a particularly potent and addictive form of the drug, best known today as “crystal meth.” All amphetamines are now banned or tightly regulated around the globe.

While produced entirely in the laboratory, amphetamines owe their existence to the search for an artificial substitute for the ma huang plant, better known in the West as ephedra. This relatively scarce desert shrub has been used as an herbal remedy in China for more than 5,000 years and is often ingested to treat common ailments such as coughs and colds and to promote concentration and alertness—including historically by night guards patrolling the Great Wall of China.

In 1887, Japanese chemist Nagayoshi Nagai successfully extracted the plant’s active ingredient, ephedrine, which closely resembled adrenaline; and in 1919, another Japanese scientist, A. Ogata, developed a synthetic substitute for ephedrine. But it was not until amphetamine was synthesized in 1927 at a UCLA laboratory by the young British chemist Gordon Alles that a formula was available for commercial medical use.

The Benzedrine inhaler hit the market in 1932 as an over-the-counter remedy for asthma and congestion. Courtesy of Wikimedia Commons.

Alles sold it to the Philadelphia pharmaceutical company Smith, Kline & French, which brought it to market as the Benzedrine inhaler in 1932 (an over-the-counter product to treat asthma and congestion), before introducing it in tablet form a few years later. “Bennies” were widely promoted as a wonder drug for all sorts of ailments, from fighting depression to obesity, with little apparent concern for or awareness of their addictive potential, and of the risks of longer-term physical and psychological damage. And thus, the stage was set for large-scale pill pushing to reach the battlefield when the next war broke out.

German, British, American, and Japanese forces ingested large amounts of amphetamines during World War II, but nowhere did the drug’s use have a more long-lasting societal impact than in Japan. The Japanese imperial government sought to give its fighting capacity a pharmacological edge, and so it contracted out methamphetamine production to domestic pharmaceutical companies for use during the war effort.

The tablets were distributed to pilots for long flights and to soldiers for combat, under the trade name Philopon (also known as Hiropin). In addition, the government gave munitions workers and those laboring in other defense-related factories methamphetamine tablets to increase their productivity.

Japanese called the war stimulants “senryoku zokyo zai” or “drug to inspire the fighting spirits.” Defense workers ingested these drugs to help boost their output. In the all-out push to increase production, strong prewar inhibitions against drug use were swept aside. It is not difficult to understand why. As researchers such as political scientist Lukasz Kamienski have documented, total war required total mobilization, from factory to battlefield. Pilots, soldiers, naval crews, and laborers were all routinely pushed beyond their natural limits to stay awake longer and work harder. In this context, taking stimulants was seen as a patriotic duty.

Kamikaze pilots took large doses of methamphetamine, via injection, before their suicide missions. They were also given pep pills stamped with the crest of the emperor. These consisted of methamphetamine mixed with green tea powder and were called Totsugeki-Jo or Tokkou-Jo, known otherwise as “storming tablets.” Most kamikaze pilots were young, often only in their late teens. Before the injection of Philopon, the pilots undertook a warrior ceremony in which they were presented with sake, wreaths of flowers, and decorated headbands.

Although soldiers from many countries returned home from the war with amphetamine habits, the problem was most severe in Japan, which experienced the first drug epidemic in the history of the country. Many soldiers and factory workers who had become hooked on the speed during the war continued to consume it into the postwar years, when it was easy to get the drugs because the Imperial Army’s post-war surplus was dumped into the domestic market.

These stockpiles of the drug then brought about other dramatic changes in Japanese society. Upon surrendering in 1945, the country had massive stores of Hiropin in warehouses, military hospitals, supply depots, and caves peppered throughout its territories. Some of the supply was sent to public dispensaries for distribution as medicine, but the rest was diverted to the black market rather than destroyed. There, the country’s Yakuza crime syndicate took over much of the distribution, and the drug trade would eventually become its most important source of revenue.

Pervitin, a methamphetamine brand that German soldiers used during WWII, dispensed the tablets in these containers. Courtesy of Wikimedia Commons.

Any tablets not diverted to illicit markets remained in the hands of pharmaceutical companies. In the wake of the traumas and dislocations of the war, a depressed and humiliated population offered an easy target. As Kamienski noted, “The pharmaceutical industry advertised stimulants as a perfect means of boosting the war-weary population and restoring confidence after a painful and debilitating defeat.” The drug companies mounted advertising campaigns to encourage consumers to purchase over-the-counter medicine sold as “wake-a-mine.” The product was pitched as offering “enhanced vitality.” In No Speed Limit: The Highs and Lows of Meth, journalist Frank Owen reports that these companies also sold “hundreds of thousands of pounds” of “military-made liquid meth” left over from the war to consumers, who did not need a prescription to purchase the drug.

With an estimated 5 percent of Japanese people between the ages of 18 and 25 taking the drug, many became intravenous addicts in the early 1950s.

Another driver of the epidemic was the existence of large, new U.S. military bases on the islands, which had never previously been occupied by a foreign power. National newspaper Asahi Shinbun wrote that U.S. servicemen were responsible for spreading amphetamine usage from large cities to small towns. Indeed, the Japanese government’s Narcotics Section arrested 623 American soldiers for drug trafficking in 1953. However, according to historian Miriam Kingsberg, most drug scandals involving U.S. soldiers garnered little coverage by the major papers out of “deference” to “American-Japanese friendship.”

Surging methamphetamine use led to increasingly strict state regulation of the drug: The 1951 Stimulant Control Law banned methamphetamine possession, and penalties were increased three years later. But these increases did not stop the rise in arrests for amphetamine abuse, which jumped from 17,500 people in 1951 to 55,600 in 1954. During the early 1950s, arrests in Japan for stimulant offences made up more than 90 percent of total drug arrests.

In an anonymous survey by the Ministry of Welfare in 1954, 7.5 percent of respondents reported having sampled Hiropon. Meanwhile the Asahi Shinbun published an estimate that 1.5 million Japanese were methamphetamine users in 1954, out of a total population of some 88 million.

The high rates of amphetamine use in Japan started to subside by the late 1950s and early 1960s, once economic growth began to create more jobs. Nevertheless, methamphetamine would remain the most popular illicit drug in Japan for decades to come.

The post The World War II “Wonder Drug” That Never Left Japan appeared first on Zócalo Public Square.

What is driving this problem and how can we combat it? In front of an engaged audience at Downtown Independent on Wednesday night, people immersed in the legal, medical, and cultural aspects of this problem offered their experiences, research, and thoughts, beginning with the origins of the epidemic.

UCLA legal scholar and health policy expert Jill Horwitz, who has been studying the laws that regulate doctors, patients, and pharmacies, said that the causes are multifaceted and include the economy, addiction, bad medicine, and corrupt pharmacists.

Sam Quinones, author of Dreamland: True Tales of America’s Opiate Epidemic, pointed to two separate causes. The first is OxyContin, which was promoted as a cure-all for pain beginning in the mid-1990s. The second is that in the 1980s, heroin—which had previously come from the Far East—started coming into America from Colombia or Mexico, making it much cheaper. “It’s potent, it’s cheap, and it’s extraordinarily mortal,” said Quinones. “It is deadlier than any epidemic we’ve ever had.”

Turning to Assistant U.S. Attorney for the Central District of California Benjamin Barron, Girion asked how law enforcement is trying to attack opioids.

Barron, who said deterring corruption among doctors is a primary focus, likened stopping opioid addiction to cutting off a many-headed monster. You can stop doctors from prescribing drugs, but you still have to deal with the black market. You can stop the abuse of prescription drugs, which has plateaued in recent years, but heroin use skyrockets. At the same time, stronger synthetic drugs are coming in from labs in China and Mexico.

Many states have instituted prescription drug monitoring programs to ensure that one person isn’t getting the same prescription from three different doctors, Girion said. But is it working?

Horwitz said that her research, including a paper she co-authored in the New England Journal of Medicine on opioid use among disabled adults, hasn’t found evidence that legal interventions make much difference.

Barron, however, disagreed. “From our perspective this has made a huge difference in taking bad actors off the market,” he said, adding that the data these programs provide is vital to his work. Furthermore, “every time we get a conviction it sends a message to doctors.”

What about helping people get medical treatment?

“The gold standard of treatment for opiate addiction is medication treatment,” said UCLA Addiction Medicine Clinic Director Larissa Mooney—drugs like methadone and naltrexone that “take the place of and break the cycle of intoxication, withdrawal, chasing the high, and trying to recover from the low.”

Another much-discussed solution, especially during the recent presidential election, is stopping the flow of heroin into the U.S. from Mexico. Girion asked Quinones, would a wall have an effect?

Walls won’t work because heroin is very easy to conceal and traffic, he said. “What we really need to do it seems to me is not alienate [Mexico],” he said. “We need to be pushing them to make the kind of changes that will make that country a kind of place that people aren’t dying to leave,” which includes better systems of law enforcement and criminal justice.

The panelists also all agreed that America’s attitude toward prescription opioids needs to change. Until the mid-1990s, doctors were reluctant to prescribe these drugs to patients unless they had terminal pain or cancer, said Girion. “Doctors’ prescribing tendencies shifted,” she said. “It got to the point where doctors were prescribing opiates quite frequently for all kinds of pain, including dental extractions and short-term pain.”

Mooney recalled seeing this “dramatic” transformation take place in medical school. “Doctors were told actually that opioids for pain are both effective and had minimal risk of addiction,” she said. “We’re learning that that is not true.”

Quinones said that the change isn’t simply limited to doctors and pointed to a larger cultural shift. “We became a country that really above all wanted comfort, convenience, and a lack of pain,” he said, citing padded playgrounds and trigger warnings in college classrooms as examples. It’s also a “story about the end of community and isolation in America,” he said. The crack epidemic largely took place in public housing, in “crack houses” where people gathered; by contrast, this epidemic is taking place in private bedrooms. “This is not a story about dope. It’s a story about who we are as a country, who we are as Americans, and what we think will lead us to happiness,” he said.

Quinones called football “a gateway to heroin addiction in America.” He found, anecdotally, that athletes with injuries are often prescribed pain pills; they’re considered the cool kids at school and on campus, and thus the drugs spread.

Girion said that her reporting supported this idea. “You go from the surgeon in the hospital to your family practitioner and your rehab, and no one pays attention to how many refills you’re getting,” she said.

“This is a supply story,” said Quinones. “If you multiply [one prescription] by millions of doctor visits and millions of surgeries over a 20-year period, that’s what creates this massive supply of opiates that transitions to heroin.”

The audience question-and-answer session pulled at one thread the panelists had touched on at various points in the discussion: race and opioid abuse. Quinones had called it a problem primarily in white America, and the panelists had all agreed that unlike other drug epidemics, this one cuts across class, affecting both affluent and poor, primarily white, Americans.

Medicare and Medicaid are contributing factors, particularly in impoverished areas. But why is there a market, asked one audience member, in more affluent places?

Quinones said that it is the result of “a generation of doctors accepting the idea that these pills can be prescribed with virtually no risk,” thanks to the work of pharmaceutical companies and pain specialists. “It was a magnificent piece of marketing,” he said.

Another audience member asked if the panel thought the level of attention given to this issue would be different if it wasn’t mainly in white communities.

Barron cautioned that at least in Los Angeles, he sees opioid addiction crossing ethnic groups, a point with which Horwitz agreed.

“It’s not that people of color cannot get hurt from this, and people of color are getting hurt from this,” she said. What’s shocking is that opioid addiction has caused a massive turnaround in the life expectancy of white people for the first time in 75 years, one that’s not seen in other racial groups, she said. As to the question about attention being paid, she wasn’t sure. “We have a fairly lousy history with dealing with problems that hit some racial groups and not others,” she said.

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