The story of CIRS, first named in 2010, begins 14 years earlier along the banks of the Pocomoke River of the Eastern Shore of Maryland. Back then, Ritchie Shoemaker, MD, was happy to be a rural, solo Family Practice physician working adjacent to wetlands of the tidal blackwater swamps around Pocomoke, Maryland. There was no need then to lock doors at night. People could walk to school without fear. Seeing patients by day, making house calls too, left ample time for a growing family to be outside in fields, forests and ponds nearby. It was an idyllic life for Dr. Shoemaker.

Life changed abruptly when Pfiesteria was found to be active in the Pocomoke River estuary where the downstream flow met the incoming salt wedge. All told, the new carrier of a never-before seen plague affected 22 tributaries of the Chesapeake Bay, possibly putting millions of people at risk for what the CDC later called Possible Estuarine Associated Syndrome (PEAS). This dinoflagellate was later identified in Bay sediments at least 100 years old, but in 1996 was acting like a newcomer, causing mysterious lesions on fish of all species. By 1997, the “Cell from Hell” expanded its activity to causing fish kills and creating an unusual illness in among watermen, people who harvested fish and crabs from the rivers and the Bay.

The public health uproar that followed the outbreak was magnified by an earlier book, The River Turned to Blood, that chronicled the Pfiesteria outbreak in North Carolina several years earlier. Only no one from Carolina admitted that anyone there was sickened in the wild. People stopped eating seafood from the Chesapeake Bay; they stopped boating on the Chesapeake Bay; life that revolved around the Bay was changed. Perhaps the scenario then was not as dramatic as COVID-19 is now regarding changing lives and changing activity because of an unknown pathogen, but the principles were the same. Fortunately, only one person was known to die from Pfiesteria.

Shoemaker was a wetland enthusiast. Everybody in Pocomoke, all 2000 people, knew him or JoAnn, his bride, an early childhood teacher in the local elementary school. He was asked by the watermen to get involved by trying to answer the questions “What is wrong with me and what do I have to do to get better?” Despite his best efforts in 1996, Shoemaker was of no help. All labs on the river, including nutrients, were unchanged; no infectious diseases were found. Every human test was non-conclusive but how could the illness be identified? What he needed were some actual confirmed human cases!

By early spring 1997, Pfiesteria was back. Shoemaker did fish autopsies, learned about wetland ecology, porewater physiology and emergent palustrine vegetation; his later insights about causation of Pfiesteria blooms were shaped by finding massive increases of heavy metals, especially copper, in the water column and in porewater directly adjacent to tomato farms and tobacco fields right next to subsequent fish kills. There, older fungicides, dithiocarbamates, had been added to copper to kill a resistant fungus that was destroying valuable crops.

All those academic