Of Bites and Men: The Most Dangerous (Urban) Game
by John S. Marr, MD, MPH, and Alan M. Beck, ScD
In December of 2017, a male passenger on a Jet Blue flight to Los Angeles from New York became agitated, leaped out of his seat and preceded to bite fellow passengers until he was restrained and removed from the plane during an emergency landing in Las Vegas. And just two years earlier, an Aer Lingus flight was diverted to Cork from its Dublin destination when a man bit a fellow passenger and then dropped dead. The news of this shocking human behavior raised many questions about the human propensity to bite, just as such reports had in 1977 when the first epidemiologic study based on a large series of human bites began…almost by accident.
“Where do you want these?” Bill Powers snarled. He was standing in front of Dr. John Marr’s cluttered desk at the New York City Department of Health. Marr was the Director of the Bureau of Preventable Diseases. He knew that the man standing in front of him had been a restaurant inspector who had only recently been reassigned to the department’s newly created Bureau of Animal Affairs. Powers was carrying three stacks of pink postcards secured by thick rubber bands. The stacks, if placed on top of each other, would be almost a foot high. Bill Powers did not appear to be in a good mood. Tall, well muscled and with a residual Irish-American lilt in his voice, he was proud of his 20-year experience as a sanitary hygienist and not happy with his abrupt reassignment a few months before.
Marr’s bureau dealt with the prevention and control of communicable diseases – tuberculosis, sexually transmitted diseases, immunization initiatives, epidemiologic investigations, and the management of five tropical disease clinics. In the past, Marr had interacted with Powers whenever there was a food-borne illness outbreak, but now Bill had new responsibilities and had become a very unhappy camper. Instead of inspecting eateries or interrogating food handlers, he now responded to dog problems – roaming feral packs in the Bronx, complaints of neighborhood barking, and, most importantly, the dozens of daily dog bites reported to his bureau. He also had to deal with citizen complaints about the quarter of a million pounds of dog droppings deposited on sidewalks and in parks throughout the city. Each day Bill begrudgingly listened to these canine fecal complaints from an angry public. He also had the chore of collating all dog (and other animal bite) reports received from hospital ERs and doctors’ offices.
In 1975 the city fathers decided that dog droppings were not under the purview of either the departments of sanitation or parks. These departments claimed that dog excrement was neither really garbage nor an environmental matter. However, after they argued that the unwanted piles were a potential health hazard, the mayor’s office added dog shit to other dog-related matters that would be handled by the health department. The health commissioner reluctantly accepted the charge and created a new bureau that he privately considered as a politically motivated dump.
Dr. Alan Beck had been hastily recruited by the New York City Health Commissioner as the new bureau’s chief. Beck had received a doctorate from Johns Hopkins and was an expert on problems associated with urban dogs. He had a relaxed appearance — open shirt, long, curly, black hair, Mephistophelian beard, and loping lupine gait — all of which should have served him quite well as the bureau director. However, a casual remark he made at an early public meeting was to follow him for years. When asked about the problem of dog excrement he answered, “Dog shit may be dog shit to some, but to me it’s my bread and butter.”
An urban legend of the time claimed that stepping in dog shit was good luck. There must have been a lot of fortunate people in the city then, and the pooper-scooper law (which Beck helped to draft) was years away. Beck settled in and began to make changes. He had a small clerical staff, a secretary, part-time veterinarian, and Bill Powers who collated the “pink cards,” which contained reports of animal bites. For Bill, they might as well have been his pink slip.
The department had a primitive method for receiving reports of infectious diseases and conditions. While reports of tuberculosis and venereal diseases were sent in sealed envelopes, all other reports were sent via franked yellow postcards. More than 50 different diseases ranging from the commonplace (measles, in the thousands) to the rare (leprosy, a few each year) were submitted on these yellow 395v cards. The name, address, age, date and time of diagnosis, reporting facility and disease were written on the back of the cards. At year’s end, stacks containing more than 200,000 cards were massive.
When Beck arrived, it was decided to create a new pink card exclusively for animal bites. It would make work easier for those who had to sort through the incoming piles. To facilitate bite reports, boxes could be checked for dog, cat, and rat bites, with a space for “other please specify.” It was reasoned that these rubrics would cover almost every contingency, but space remained after the “other” check box. They considered human as a whimsical solution, and put an additional check box for human bites.
In the fall, 100,000 pink cards had been distributed to all health care providers in the city. By the following spring, Bill Powers had laboriously sorted the previous year’s reports, organizing bites by animal. “Dr. Beck kept all the animal bite reports,” Powers said to Marr sourly, “but these cards are the human bites.” He dropped the stacks on the desk and angrily stalked out to deal with some new scatological assignment. Doctors in ERs, clinics, and hospitals had submitted this tower of cards. Marr imagined that Powers had done the same to Beck, pouring a veritable avalanche of 25,000 animal bite pink cards on his desk — the revenge of a sorcerer’s apprentice.
In the 1970s, there were no computer-generated spreadsheets to analyze the information written on disease reports. Data had to be entered onto a Bob Cratchet-like ledger, item by item. After recording totals, raw data on a particular disease or condition was eyeballed; a decision was made whether it was worth the effort to look further by exact time, place, and person; if so, each card’s specifics had to be transferred to an individual IBM punch card, which could not be bent, spindled, or folded. A Volkswagen Beetle-sized IBM computer needed constant supervision as the cards were loaded; if a card had the slightest imperfection, it would cause a shutdown. Marr asked himself if it was worth the time and trouble to organize the results of 892 human bites. Intrigued, he decided to analyze the work on weekends, creating a list of standard epidemiologic categories of time, place, and person characteristics.
By doing this at home, he avoided being nominated for then-United States Senator William Proxmire’s annual Golden Fleece Awards that were notoriously given to a government agency for wasting time and taxpayers’ money. He recalled the classic tag line in the 1948 film noir The Naked City: “There are eight million stories in the naked city; this has been just one of them.” Perhaps the cards contained one additional tale about Gotham’s denizens.
Beck and Powers separated the dogs from cats and other animal bites. Dogs were their major concern; the bite total was an impressive 22,078. Beck knew that only one in five dog bites and puppy nips were reported, so the true annual count of 100,000 was sobering. There were also an additional 1,700 bites from other usual suspects: 1,152 cats and 548 rats. The remainders were the so-called “exotics”: 40 rabbits, 21 monkeys, 15 horses, 11 snakes, 5 turtles, 4 parrots, 4 raccoons, 3 lions, 3 ferrets, 2 donkeys and geese, and single bites from a pony, lizard, rooster, blue jay, ocelot, leopard, polar bear, and anteater. He suspected a few of these more outrageous reports were fabrications. However, when considering these totals, they had probably greatly underestimated the overall number since many trivial nips from pets were not serious enough to seek medical attention. The same was probably true of human love bites.
Marr had met what he thought was a health department vet on his first day on the job four years before. Dr. Louis Woods (not his real name) introduced himself as the department’s “vector control expert” (his designation). He proudly announced that he was the expert who was sent out to euthanize dangerously aggressive dogs. Louis was a slightly built man with scraggy gray hair that matched his crumpled gray suit. It was nine in the morning and Marr smelled Scotch through Woods’ cigarette breath. (A wake-me-upper among long-time employees was not unknown at the time, but Louis was already drunk.) The next day, he showed Marr his arsenal of dart guns, vials of fluid labeled Euthacide, and his private office in a stygian, well-hidden, windowless room in the bowels of the building. Over the years, he had somehow usurped complaints of insect infestations and had expanded his alleged expertise to eliminating all sorts of dangerous animals, both large and small. He told Marr he also dealt with complaints that no veterinarian wanted to deal with — vicious dogs.
Louis had demonstrated his euthanizing dart gun to one of Marr’s associates in his secret lair, where he had erected a practice target. He drunkenly waved the gun towards the wall and fired the poison dart, but his aim was off. The dart shattered a large fish aquarium, spilling the fish onto the floor. The associate fled in panic while Woods scrambled to save his fish.
Woods had been at the department for ages, and somehow survived five previous commissioners – none had ever met him or knew what service he performed until a potentially fateful event occurred. One morning, Woods saw a half-page advertisement in The New York Times for a “safari event” at the B. Altman’s department store. The ad depicted a lithe model in full safari gear holding a leashed lion cub. He was immediately alerted and called the store, identified himself, and demanded to talk to the president. Somehow he got through to the man and explained that wild animals were against city regulations and that he was going to close the store immediately. When the flustered man asked whom he reported to Woods retorted, “I answer to no man at the health department!” A few minutes later, the commissioner received a call from the mayor’s office demanding to know just who this Dr. Woods was. He had no idea who Woods was and began to make inquiries. Warned of the inquiry, the man retreated to his grotto and no one could find him. The incident passed. He had survived his first close encounter with a commissioner. Later, Marr discovered that Woods’ postgraduate degree was not in veterinarian medicine but human chiropractic.
There was an unusual animal bite from the previous year that had not been included in the card reports. Sometime that summer, Marr overheard his secretary reassuring a person over the telephone, “No, don’t worry, fish can’t transmit rabies.” He was intrigued and asked who had made the call. She told him that a large piranha had nipped a fingertip off a Bronx resident who unwisely chose to dangle his finger in a methadone clinic’s aquarium. The victim had been sent to a local ER for treatment, hence the call. Marr called back and found the clinic address. The piranha was confiscated (without the assistance of Dr. Woods). An autopsy failed to reveal the fingertip.
Alan Beck had inherited a vestigial veterinarian unit consisting of a single part-time vet. By the early 1970s, animal-related diseases had largely disappeared from the city. Contrary to what some historians claimed, bubonic plague had never visited New York City; psittacosis had been eliminated in the 1940s; Rocky Mountain spotted fever existed on Long Island but not within the five boroughs (some cases were occasionally imported by weekend vacationers to the Hamptons); Lyme disease had just been discovered in Connecticut. There was one lingering zoonotic concern – rabid bats. Terrestrial rabies had historically been the main driving force for public health veterinarians, but rabid mammals had disappeared long ago in the city. The last human case had died in 1944; the last rabid cat was in 1948, and last rabid dog in 1954. However, the anti-rabies injections for dog bites had continued, and Beck and Marr had been given the task to update guidelines for treatment.
Bat bites remained as a potential public health problem. They were being recognized around the country as a new source of rabies. Fortunately, there were no bat bite reports in the previous year; but three months before, the city Bureau of Laboratories reported its first rabid bat. The bat had been picked up by Brooklyn police after two children were found playing catch with it. The officers had not asked if they had been bitten; they had an address, but no names or telephone numbers for the boys. Beck commandeered a patrol car, and with lights flashing, he and Marr cut through rush-hour traffic to the address where they found the kids playing on the sidewalk. The boys told Marr and Beck that the bat had been dead and that none of them had touched its teeth. It was decided the boys didn’t need rabies shots. At the time, the rabies treatment consisted of 21 injections over a three-week period—something to be avoided if at all possible.
The significance of the human bite has never been fully explored, though it is estimated that half of all Americans will probably suffer a human or animal bite during their lifetimes. Vampires chomp away in popular fiction, Hannibal Lecter enjoyed a good chomp, and Buffy the Vampire Slayer would play well on TV in the future. But factual references to those truly bitten and those who choose to bite had not received much attention. Using concordances at the public library, Marr discovered instances referencing human bites in the Old Testament, Chaucer, Shakespeare, Spenser, Pope, Roethke, Ralph Waldo Emerson, Stephen Crane, Robert Frost, George Bernard Shaw, and Eugene O’Neill. Anthropologists and folklorists have also documented human biting in tribal beliefs and in ancient Greek and Roman myths. Tales about vagina dentate were also found. This rare medical condition occurs when ectopic teeth from a retained twin lodge anywhere within a woman’s abdomen as a “dermal cyst.” The remnants in a cyst contain hair, bone, and teeth. Some have been found in the vagina. Queen Elizabeth (the Virgin Queen) allegedly had one ectopic tooth (that may have explained her celibacy).
Over the years, human bites occasionally make the headlines if they are spectacular enough. The favorites are bites to or amputations of the penis. Sports events also draw attention, whether the bite was by accident or purposeful. In 1997, Mike Tyson, in what is now called the “bite fight,” bit Evander Holyfield twice. Bites have also been featured as newsworthy when they occur during soccer, hockey, and football games.
Aside from mutilation or amputation, human bites had always been considered as a serious medical consequence. Albert Schweitzer considered the human bite the most serious of all animal bites, and indeed a large portion of the infectious disease literature has been devoted to human bites and the 700 or so species of bacteria that can typically be found in a human mouth. Even a playful love bite can be quite serious, leading to viral (herpes, HIV), bacterial (syphilis, tetanus), and various fungal infections. But medical reports — whether a single case or series of cases — were limited. Marr and Beck thought an epidemiological approach might be an original contribution to the literature. They knew that their study would be a first, giving an overview and descriptive analysis to what had otherwise been anecdotal and clinical accounts. The analysis might document what had been a heretofore under-appreciated anti-social act.
All conditions and diseases that are reported to the health department, from lead poisoning to falls from a window, can be organized using three factors: time, place, and person, or the who, what, when, and where. The two men had identified the “who” and “what” —human bites—but the standard questions of when and where needed to be examined further. Plotting each major query separately might give a clue, but they had to be integrated with each other to create the final why in order to pose a logical hypothesis. When the three separate queries pin down hard factual data, it is referred to as “descriptive epidemiology.” The final why is a conjectural extension — “analytical epidemiology” — where hypotheses are posed to answer the why?
Time was broken down by month and day of the week, which were the easiest to analyze. The 892 bites were a sufficiently large number that some pattern might be detected when plotted on graphs by time intervals. The overall monthly bite average was 75. When bites were graphed by month they correlated quite nicely with the city’s monthly temperatures — low numbers in the wintertime, and highest in the summertime. Bites peaked during June and July but slowly declined in August. January and February had the lowest monthly bite rates, along with November and December — the coldest months of the year. Was this link between bites and temperature a happenstance correlation, or were they causally connected in some way? When weekly averages were graphed, overall bites appeared to be evenly distributed throughout a seven-day week with no particular day favored. They reasoned that additional information on person and place might show a different pattern.
Place and person characteristics required generating rates, or in epidemiologic terms attack rates, a term which certainly appeared to be appropriate to the task. The standard attack rate in epidemiologic investigations is the number of cases of a specific disease or condition (in this case, bites) within a group divided by 100,000 people in that group. The citywide human bite rate (11.8 per 100,000) acted as a comparison with all place and time rates. Common person groups were age, sex, occupation, and race, but the cards did not have information on the latter. To generate age and sex attack rates, city census data were used, breaking down populations by the five boroughs and further into 30 smaller health districts. Manhattan had seven health districts, Brooklyn 10, the Bronx and Queens six each, and Staten Island (Richmond) one. Additional places of occurrence included a general location: inside a building or outside in a park, playground, or street. A majority of city bites seemed to have occurred inside dwellings (not including six people bitten inside an automobile or scuffles in a squad car); however, outside bites were much more common in the summer months.
The overall city hallmark of 11.6/100,000 could be compared to smaller borough and district rates. Bite rates were much more common in Brooklyn — four of the top five city districts were from that borough; Brooklyn had five of its six districts in the top tier. The highest Brooklyn district rate was in Fort Greene with 60 bites per 100,000 people –well over five times the overall average (60 vs. 11.6). This single epicenter spilled over into the contiguous neighborhoods of Bedford (33/100,00), Williamsburg/Greenpoint (29/100,000) and Red Hook/Gowanus (21/100,000). East Jamaica in Queens, on the other hand, was the best place to avoid being bitten, the lowest rate of all — 0.9/100,000). Only three human bites had been reported in that peaceful neighborhood throughout the entire year. The men mused about the possibility that urban vampires were stalking Brooklyn, and that a large edentulous elderly population living in East Jamaica were just gumming each other.
The age rates were a bit surprising. Although bites occurred in all age groups from toddlers to senior citizens, bites were more common after 10 years of age, and much less common after 40 years. The highest rate was in victims between 30-34 years of age. By gender, about two thirds of all bites were in males, except for girls between 10-20 years old where they suspected teenage “cat fights” as an explanation.
But what was truly fascinating was that when certain age and gender groups were further examined by month and day — a Saturday night epidemic began to emerge. When males between the ages of 16-30 years were put alongside month and day of the week, there was an exaggerated upswing of bites during the warmer months, especially on Saturdays. None of the other age groups showed any difference in bite rates during the week. Another observation suggested the reason for the Saturday phenomenon: 72 percent of bites were associated with fighting, police arrests, and muggings. Unaggressive and accidental behaviors that led to bites (playing, medical treatment, and sexual activities [only two]) had accounted for only 23 percent of the bites.
The part of the body bitten supported a growing hypothesis that fist fighting was the most common cause. There were 546 bites to the upper extremity; and only 133 to the head and neck; 103 to the trunk; 33 to lower extremities. (In 77 incidents, the site on the body was not listed). Over half of upper extremity bites were on the hand, knuckles, or fingers. The investigators imagined a scene in a bar, alley, or in a home on a hot Saturday night when a disagreement led to a fist fight. The puncher, however, was the victim of the bite when he hit his opponent with a fist. But why Brooklyn; why in Fort Greene? It wasn’t due to biased or over-reporting since reports of common diseases from their hospitals did not suggest a selective, overzealous reporting of human bites.
Dr. Beck was a Brooklyn native, a Thomas Jefferson High School and Brooklyn College alumnus. Marr was born and raised in Manhattan and had gone to medical school in the city, later spending a residency at a Spanish Harlem hospital. The two both knew enough about New York City–where to go and when, and where not to go—to avoid problems. They knew that Fort Greene was in northwestern Brooklyn, south of the Navy Yard, and was a neighborhood that had suffered unemployment and poverty since World War II. It was cited by an urban commission as “one of the starkest examples of the failure of public housing.” But what kind of denizens inhabited that neighborhood?
The health department had some vital statistical data on births and deaths but not data on injuries associated with crime. Marr decided to ask the New York City Police Department about their perspective on Fort Greene citizens, so he walked up a few blocks from the health department to the new police headquarters at 1 Police Plaza. The so-called Plaza was a 13-story brutalist-style building, contrasting with the surrounding squat tenements of nearby Chinatown and the block-like monolithic health department.
How was he going to introduce himself and explain his interest in human bites to an officer? He did have an official badge–a Dick Tracy-sized bronze badge dating back to the 1930s–as large and thick as a sugar cookie. It had the word DIRECTOR in faux silver draped over a worn crest of the city with smaller lettering spelling out New York City Health Department on its bottom. He doubted any policeman had ever seen such a relic, but hopefully with his ID, it might convince an officer that he was legit. He explained to the receptionist that he was from the health department and wished to talk with an officer about some health concerns in the Fort Greene area.
The officer he was directed to talk with was a portly sergeant with white hair and a lot of ribbons decorating his uniform; he looked like he would be retiring soon. The health department I.D. sufficed. Marr told him that he was looking into a health matter in Fort Greene but was purposely vague about what that matter might be. The officer told him that the 88th police precinct in that section of Brooklyn was a very high crime area. Drug-related crimes (robberies, muggings, break-ins) were the highest in the city. Marr told him he also found that certain diseases like drug-associated hepatitis and heroin overdose/deaths were also “epidemic,” in that district, but Marr did not mention the bites. It appeared that both departments agreed that Fort Greene was a dangerous place to be, both day or night, inside house, home, or bar, or out on the mean streets of a concrete jungle.
Fast forward to 2019, and Fort Greene is a much different place. With the gentrifying of all of Brooklyn, crime rates have fallen by 75 percent, and we presume “bite rates” have fallen, too. Now home to the hip and famous like Spike Lee and Rosie Perez, town houses sell for upwards of $4 million.
However, when Marr returned to the bureau in 1977, he talked with Beck, confirming what they had suspected about violence in Fort Greene. They both wondered aloud whether they should venture into the health district and talk with hospital ER staff and Fort Greene residents to see if they could learn more. A warm summer Saturday night would be the perfect time. Marr then recalled a throwaway line from Casablanca that was to determine what they should do next. In the movie, at Rick’s Café, Rick (Bogie) is introduced to a German officer, Major Strasser. Strasser asks Rick about a German occupation of New York City. Bogie answers, “Well, Major, there are certain sections of New York that I wouldn’t advise you to try to invade.” Fort Greene was probably one of those sections, Marr suspected. He and Beck decided not to pursue a further investigation of Fort Greene’s inhabitants any further and let that sleeping dog lie. It might bite them if disturbed.
- Bat bites are a potential public health problem. A report of a rapid bat is described in this case. The bat had been picked up by Brooklyn police after two children were found playing catch with it. The boys stated that the bat had been dead and that none of them had touched its teeth. It was decided the boys didn’t need rabies shots. At the time, the rabies treatment consisted of 21 injections over a three-week period—something to be avoided if at all possible. Under what conditions would you have recommended rabies prophylaxis? What is the current regimen?
- The highest rate was in victims between 30-34 years of age. By gender, about two thirds of all bites were in males. Can you explain this pattern?
- Public health agencies are responsible for the management of individuals who experience animal bites. Should they also be responsible for animal control? An animal control service or animal control agency is an entity charged with responding to requests for help with animals ranging from wild animals, dangerous animals, or animals in distress.
ABOUT THE AUTHORS
John S. Marr, MD, MPH, is the former State Epidemiologist for the Virginia State Department of Health. At the time of this case, he served as the Director of the Bureau of Preventable Disease for the New York City Department of Health.
Alan M. Beck received his Doctor of Science (ScD) in Animal Ecology from The Johns Hopkins University School of Public Health. He has studied the ecological and public health implications of dogs and the health benefits of animal contact. Beck directed the animal programs for the New York City Department of Health for five years, and then was the Director of the Center for the Interaction of Animals and Society at the University of Pennsylvania, School of Veterinary Medicine for 10 years. Dr. Beck is now the “Dorothy N. McAllister Professor of Animal Ecology” and Director of the Center for the Human-Animal Bond at Purdue University, College of Veterinary Medicine, West Lafayette, Indiana.
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- Introducing a New Series of Epidemiologic Case Studies: Podcast with Dr. John Marr
Read more Backstories in Epidemiology: True Medical Mysteries, coming soon:
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