Micah Thorp

The Fourth Horseman

The Plague of the Philistines at Ashdod by Pie Wellcome

Waikiki beach had been packed for the evening fireworks show.  Shoulder to shoulder, tens of thousands of people stood on the white sand in the heat of July, waiting to observe the truncated, obligatory Independence Day show.  The crowd was loud, pushy and crass.  A large beet red septuagenarian dropped his BBQ ribs on my plaid shorts, while a Chinese tourist screamed something to the leader of her tour group directly into my ear.  I was hot, annoyed and tired.  I looked at my wife.  “We need a plague.”

In the moment it was funny, sardonic.  A day later I regretted the remark.


The first cases were simply medical oddities:  a strange pneumonia, an unusual skin condition, the kind of cases one occasionally sees in a large teaching hospital.  Diseases that while epidemiologically rare, occur with great enough frequency that now and again a patient will present with one of them.  As medical residents, having seen enough common ailments to become bored, the new and unusual cases were refreshingly interesting.  We pored through the medical literature, presented the cases at various meetings and wrote lengthy notes about assessments and potential treatments.  Our consultants and faculty bloviated, ask for ever more obscure tests, and prescribed whatever medication the pharmaceutical representatives had recently detailed.  It was all very exciting.  Only a few of the most senior physicians, those old enough to remember cases of polio and mumps, worried.

The Centers for Disease Control’s MMWR published new information at a rate faster than most medical journals.  In an era where electronic data was limited, it offered the first obscure glimpses of what was to come.  A virus, HTLV-III had been identified in the United States while an identical virus, LAV had been discovered in France.  Researchers had identified the virus which had been linked to many of the rare diseases we were seeing.  Yet with no widely available test, it was impossible to tell whether a disease in a specific patient was due to the virus.

Within a year the rare diseases were not.  Names that had previously been obscure were commonplace.  A new vocabulary evolved.  Castleman’s, Kaposi’s, pneumocystis, toxoplasmosis and cryptosporidium entered the lexicon.  A test for the virus was developed and disseminated.  Now called Human Immunodeficiency Virus, its presence explained the sharp increase in patients we had seen a year earlier.

The victims were mostly, though not exclusively, gay men.  Having been ostracized by family, many feared hospital admissions would further erode their limited social support.  Often, the young men would die with a “friend” at the bedside grieving, unable to reveal the nature of their relationship, nor exercise what should have been spousal rights.  Death came quickly, often painfully, isolated and alone.  Frequently their only company were those of us caring for them.

While it was clear the cause of AIDS was the HIV virus, uncertainty existed regarding the ease of transmission.  For a time, no one knew whether an errant drop of blood, a needle stick or a transfusion might transmit the virus.  Fear often trumped logic, leading to ridiculous assumptions about who might be at risk of infection and how a caregiver might become infected.  At some point everyone who cared for a patient with HIV would feel the terror of a potential needlestick, a torn glove, or the exposure to an undiscovered vector.

In time, as with most disease outbreaks, the intensity of the outbreak waned.  Treatments became available reducing HIV infection from a death sentence to a managed chronic disease. The early fears faded, and AIDs took its place alongside other common chronic maladies.


The world is becoming, as Tom Friedman notes, hot, flat and crowded.  A serious case can be made that there are simply too many of us.  Nature may, or may not, ultimately provide some Malthusian solution.  But I hope it isn’t a plague.  I remember the fourth horseman.  I fear him.  It is a fear I will not again forget.


About the writer:
Micah Thorp is a physician and writer in Portland, Oregon.

Image: The Plague of the Philistines at Ashdod by Peter van Halen (1612-1687). Oil on canvas. 84.8 x 119.5 cm. 1661. Public domain via Pie Wellcome.