The Age-Old Fight for Better Health

JOANNE lived in New York, and she had tuberculosis (TB). But her disease was not a typical TB case. She had a mutant strain that is resistant to practically all drugs and that kills half of its victims. Joanne, however, did not seek treatment regularly, and she had already caused at least one TB outbreak. ‘She should be locked up,’ said her frustrated doctor.

TB is a very old killer. Literally millions of people have suffered and died from TB. Evidence of the disease has been found in mummies from ancient Egypt and Peru. Today, resurgent strains of TB kill some two million people every year.

Carlitos, lying on a small cot in an African hut, had beads of perspiration on his forehead. Malaria had made him too weak even to cry. His anxious parents had no money for medicine, and there was no clinic nearby where they could get medical attention for their young child. The fever did not relent, and within 48 hours he was dead.

Malaria kills nearly one million children like Carlitos every year. In East African villages, the average child is bitten by malaria-carrying mosquitoes between 50 and 80 times a month. These mosquitoes are spreading to new areas, and antimalarial drugs have become less effective. Every year, an estimated 300 million people suffer from acute malaria.

Kenneth, a 30-year-old man living in San Francisco, California, first went to his doctor in 1980. He complained of diarrhea and tiredness. A year later he was dead. Despite expert medical attention, his body just wasted away, and he finally succumbed to pneumonia.

Two years later and 10,000 miles [16,000 km] from San Francisco, a young woman in northern Tanzania began to suffer from similar symptoms. In a few weeks, she could no longer walk, and soon thereafter she died. The villagers dubbed the strange sickness Juliana’s disease because a man selling cloth decorated with the name Juliana had apparently infected her and other local women.

Both Kenneth and the Tanzanian woman had the same disease: AIDS. At the beginning of the 1980’s, just when it seemed that medical science had tamed the most dangerous microbes, this new infectious disease arose to haunt humanity. Within two decades the AIDS death toll began to rival that of the plague that swept across Eurasia in the 14th century​—a plague that Europe never forgot.

The Black Death

The outbreak of the plague called the Black Death can be traced to 1347, when a ship from the Crimea berthed in Messina, on the island of Sicily. Apart from its regular cargo, the ship also carried the plague.a Soon the Black Death spread throughout Italy.

The following year Agnolo di Tura, of Siena, Italy, described the horror in his hometown: ‘The mortality in Siena began in May. It was a cruel and horrible thing. The victims died almost immediately. They died by the hundreds, both day and night.’ He added: ‘I buried my five children with my own hands, and so did many others likewise. Nobody wept no matter what his loss because almost everyone expected death. So many died that all believed it was the end of the world.’

Within four years, say some historians, the plague spread throughout Europe and about a third of the population lost their life​—perhaps between 20 million and 30 million people. Even remote Iceland was decimated. It is said that in the Far East, the population of China slumped from 123 million at the beginning of the 13th century to 65 million during the 14th century, apparently as a result of the plague and the accompanying famine.

No previous epidemic, war, or famine had ever caused such widespread suffering. “It was a disaster without equal in human history,” notes the book Man and Microbes. “Somewhere between one-quarter and one-half of the people in Europe, North Africa, and parts of Asia perished.”

The Americas escaped the ravages of the Black Death, thanks to their isolation from the rest of the world. But oceangoing ships soon brought that isolation to an end. In the 16th century, a wave of epidemics that proved even more lethal than the plague ravaged the New World.

Smallpox Conquers the Americas

When Columbus arrived in the West Indies in 1492, he described the native people as being of ‘pleasing appearance with fine features and medium height with muscular bodies.’ Their healthy appearance, however, belied their vulnerability to the diseases of the Old World.

In 1518 an outbreak of smallpox erupted on the island of Hispaniola. Native Americans had never been exposed to smallpox before, and the effect was catastrophic. A Spanish eyewitness estimated that only a thousand people on the island survived. The epidemic soon spread to Mexico and Peru, with similar consequences.

The following century, when the Pilgrim settlers arrived in the area of Massachusetts in North America, they discovered that smallpox had practically cleared the land of inhabitants. “The natives, they are near all dead of the smallpox,” wrote Pilgrim leader John Winthrop.

Other epidemics followed smallpox. According to one source, by a century after Columbus’ arrival, imported diseases had wiped out 90 percent of the population of the New World. The population of Mexico had shrunk from 30 million to 3 million, that of Peru from 8 million to one million. Native Americans, of course, were not the only victims of smallpox. “Over the course of human history, smallpox claimed hundreds of millions of lives, far more than plague . . . and all the wars of the twentieth century combined,” notes the book Scourge​—The Once and Future Threat of Smallpox.

The War Has Not Yet Been Won

Nowadays, the horrific epidemics of plague and smallpox may seem like catastrophes long since consigned to the pages of history. During the 20th century, mankind won many battles in the war against infectious diseases, especially in industrialized countries. Doctors discovered the causes of most diseases, and they also found ways to cure them. (See the box below.) New vaccines and antibiotics seemed like magic bullets capable of exterminating even the most stubborn disease.

However, as Dr. Richard Krause, former director of the U.S. National Institute of Allergy and Infectious Diseases, points out, “plagues are as certain as death and taxes.” TB and malaria have not gone away. And the recent AIDS pandemic has provided a grim reminder that pestilence still stalks the globe. “Infectious diseases remain the world’s leading cause of death; they will remain so for a long time to come,” states the book Man and Microbes.

Some doctors fear that despite remarkable progress in fighting disease, the gains of the last few decades may only be temporary. “The danger posed by infectious diseases has not gone away​—it’s worsening,” warns epidemiologist Robert Shope. The following article will explain why.

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Within two decades the AIDS death toll began to rival that of the plague that swept across Eurasia in the 14th century

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Knowledge Versus Superstition

In the 14th century, when the Black Death threatened the pope’s household in Avignon, his doctor informed him that the conjunction of three planets​—Saturn, Jupiter, and Mars—​in the sign of Aquarius was the principal cause of the plague.

Some four centuries later, George Washington went to bed with a sore throat. Three eminent doctors treated the infection by draining some two quarts [2 L] of blood from his veins. Within a few hours, the patient was dead. Bloodletting was standard medical practice for 2,500 years​—from the time of Hippocrates until the mid-19th century.

Although superstition and tradition delayed medical progress, dedicated doctors worked hard to discover the causes of infectious diseases and remedies for them. Below are a few of the significant breakthroughs they made.

◼ Smallpox. In 1798, Edward Jenner successfully developed a vaccine for smallpox. During the 20th century, vaccines have proved effective in preventing other diseases, such as polio, yellow fever, measles, and rubella.

◼ Tuberculosis. In 1882, Robert Koch identified tuberculosis bacteria and developed a test for the disease. Some 60 years later, streptomycin, an effective antibiotic for treating tuberculosis, was discovered. This drug also proved useful for treating bubonic plague.

◼ Malaria. From the 17th century onward, quinine​—obtained from the bark of the cinchona tree—​saved the lives of millions of malaria sufferers. In 1897, Ronald Ross identified Anopheles mosquitoes as the carriers of the disease, and mosquito control was later promoted to reduce mortality in tropical countries.

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Zodiac chart (above) and bloodletting

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Both: Biblioteca Histórica “Marqués de Valdecilla”

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Today, resurgent strains of tuberculosis kill some two million people every year

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X ray: New Jersey Medical School–National Tuberculosis Center; man: Photo: WHO/Thierry Falise

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A German engraving, dating from about 1500, depicts a doctor wearing a mask to protect against the Black Death. The beak contained perfume

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Godo-Foto

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The bacteria that caused the bubonic plague

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© Gary Gaugler/Visuals Unlimited

Successes and Failures in Fighting Disease

ON August 5, 1942, Dr. Alexander Fleming realized that one of his patients, a friend, was dying. The 52-year-old man had contracted spinal meningitis, and despite all of Fleming’s efforts, his friend had now sunk into a coma.

Fifteen years earlier, Fleming had stumbled on a remarkable substance produced by a bluish-green mold. He called it penicillin. He noticed that it had the power to kill bacteria; but he could not isolate pure penicillin, and he tested it only as an antiseptic. In 1938, however, Howard Florey and his research team at Oxford University took up the challenge of producing a sufficient quantity of the drug for trials on humans. Fleming called up Florey, who offered to send all the penicillin he had available. It was Fleming’s last chance to save his friend.

An intramuscular injection of penicillin proved insufficient, so Fleming injected the drug directly into his friend’s spine. The penicillin destroyed the microbes; and in just over a week, Fleming’s patient left the hospital completely cured. The era of antibiotics had dawned, and a new milestone had been reached in mankind’s fight against disease.

The Age of Antibiotics

When they first appeared, antibiotics seemed like wonder drugs. Hitherto incurable infections caused by bacteria, fungi, or other microorganisms could now be treated successfully. Thanks to the new drugs, deaths from meningitis, pneumonia, and scarlet fever declined dramatically. Hospital infections that had formerly meant a death sentence were cleared up in a few days.

Since the time of Fleming, researchers have developed dozens of additional antibiotics, and the search for new ones continues. During the last 60 years, antibiotics have become an indispensable weapon in the fight against disease. If George Washington were alive today, doctors would doubtless treat his sore throat with an antibiotic, and he probably would recover in a week or so. Antibiotics have helped practically all of us shrug off one infection or another. However, it has become apparent that antibiotics do have some drawbacks.

Antibiotic treatment does not work for diseases caused by viruses, such as AIDS or influenza. Furthermore, some people have an allergic reaction to certain antibiotics. And broad-spectrum antibiotics may kill off the helpful microorganisms in our bodies. But perhaps the greatest problem with antibiotics is their overuse or underuse.

Underuse occurs when patients do not complete the prescribed antibiotic treatment, either because they feel better or because the treatment is lengthy. As a result, the antibiotic may not kill off all the invading bacteria, allowing resistant strains to survive and multiply. This has frequently happened in the case of treatment for tuberculosis.

Both doctors and farmers have been guilty of overuse of these new drugs. “Antibiotics have often been overprescribed in the United States, and they are used even more indiscriminately in many other countries,” explains the book Man and Microbes. “They have been fed in huge quantities to livestock, not to cure disease but to aid growth; this is a major reason for heightened microbial resistance.” The result, the book warns, is that “we may be running out of new antibiotics.”

But apart from these concerns about antibiotic resistance, the second half of the 20th century was a time of medical triumphs. Medical researchers seemed capable of finding drugs to fight practically any malady. And vaccines even offered the prospect of preventing disease.

Victories for Medical Science

“Immunization is the greatest public health success story in history,” stated The World Health Report 1999. Millions of lives have already been saved, thanks to massive worldwide vaccination campaigns. A global immunization program has eliminated smallpox​—the lethal disease that claimed more lives than all the wars of the 20th century combined—​and a similar campaign has almost eradicated polio. (See the box “Triumphs Over Smallpox and Polio.”) Many children are now vaccinated to protect them against common life-threatening diseases.

Other diseases have been tamed by less-dramatic methods. Such waterborne infections as cholera rarely cause problems where there is adequate sanitation and a safe water supply. In many lands increased access to doctors and hospital care means that most diseases can be identified and treated before they become lethal. Better diet and living conditions, along with enforcement of laws regarding proper handling and storage of food, have also contributed to improving public health.

Once scientists tracked down the causes of infectious diseases, health authorities could take practical steps to halt an epidemic in its tracks. Consider just one example. An outbreak of bubonic plague in San Francisco in 1907 killed few people because the city immediately launched a campaign to exterminate the rats whose fleas transmitted the disease. On the other hand, starting in 1896, the same disease had caused ten million deaths in India within 12 years because its underlying cause had not yet been identified.

Failures in Fighting Disease

Clearly, significant battles have been won. But some public health victories have been confined to the richer countries of the world. Treatable diseases still kill millions of people, simply for lack of sufficient funds. In developing countries many people still lack adequate sanitation, health care, and access to safe water. Fulfilling these basic needs has become more difficult on account of massive migrations of people from the countryside to the megacities of the developing world. As a result of such factors, the world’s poor suffer what the World Health Organization calls a “disproportionate share of the burden of disease.”

Shortsighted selfishness is the principal cause of this health imbalance. “Some of the world’s worst infectious killers seem distant,” states the book Man and Microbes. “Some of these are limited entirely or mainly to poor tropical and subtropical regions.” Since wealthy developed countries and pharmaceutical companies may not benefit directly, they begrudge allocating funds for the treatment of these diseases.

Irresponsible human behavior is also a factor in spreading disease. In no way is this harsh reality better illustrated than in the case of the AIDS virus, which spreads from one person to another through body fluids. Within a few years, this pandemic has swept across the globe. (See the box “AIDS​—The Scourge of Our Time.”) “Human beings have done it to themselves,” asserts epidemiologist Joe McCormick. “And that’s not moralistic, it’s just a fact.”

How did humans unwittingly cooperate with the AIDS virus? The book The Coming Plague lists the following factors: Social changes​—especially the practice of having multiple sex partners—​led to a wave of sexually transmitted diseases, making it much easier for the virus to take hold and for one carrier to infect many other people. The widespread use of contaminated, secondhand syringes for medical injections in developing countries or for illicit drug use had a similar effect. The billion-dollar global blood industry also enabled the AIDS virus to pass from one donor to dozens of recipients.

As mentioned earlier, the overuse or underuse of antibiotics has contributed to the appearance of resistant microbes. This problem is serious and is getting worse. Staphylococcus bacteria, which often causes wound infections, used to be eliminated easily by penicillin derivatives. But now these traditional antibiotics are often ineffective. So doctors must turn to newer, expensive antibiotics that hospitals in developing countries can rarely afford. Even the newest antibiotics may prove unable to combat some microbes, making hospital infections more common and more deadly. Dr. Richard Krause, former director of the U.S. National Institute of Allergy and Infectious Diseases, bluntly describes the current situation as “an epidemic of microbial resistance.”

“Are We Better Off Today?”

Now, at the start of the 21st century, it is clear that the threat of disease has not disappeared. The relentless spread of AIDS, the appearance of drug-resistant pathogens, and the resurgence of age-old killers like tuberculosis and malaria show that the war on disease has not yet been won.

“Are we better off today than we were a century ago?” asked Nobel Prize winner Joshua Lederberg. “In most respects, we’re worse off,” he said. “We have been neglectful of the microbes, and that is a recurring theme that is coming back to haunt us.” Can the present setbacks be overcome with determined effort by medical science and all nations of the world? Will the principal infectious diseases eventually be eradicated, as smallpox was? Our final article will consider these questions.

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Triumphs Over Smallpox and Polio

At the end of October 1977, the World Health Organization (WHO) tracked down the last-known naturally occurring case of smallpox. Ali Maow Maalin, a hospital cook who lived in Somalia, did not get a severe attack of the disease, and he was well again within a few weeks. All people in contact with him were vaccinated.

For two long years, the doctors waited anxiously. A $1,000 reward was offered to anyone who could report another confirmed “active smallpox case.” Nobody successfully claimed the reward, and on May 8, 1980, WHO formally announced that “the World and all its peoples have won freedom from smallpox.” Just a decade earlier, smallpox was causing the death of about two million people a year. For the first time in history, a major infectious disease had been eliminated.a

Polio, or poliomyelitis, a debilitating childhood disease, offered the prospect of similar success. In 1955, Jonas Salk produced an effective vaccine for polio, and an immunization campaign against polio began in the United States and other countries. Later an oral vaccine was developed. In 1988, WHO launched a worldwide program to eliminate polio.

“When we began the eradication effort in 1988, polio paralysed more than 1000 children each day,” reports Dr. Gro Harlem Brundtland, then director general of WHO. “In 2001, there were far fewer than 1000 cases for the entire year.” Polio is now confined to fewer than ten countries, although more funds will be needed to help these lands finally eliminate the disease.

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An Ethiopian boy receives an oral polio vaccine

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© WHO/P. Virot

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AIDS​—The Scourge of Our Time

AIDS has emerged as a new global threat. Already, about 20 years after its identification, more than 60 million people have been infected. And health authorities warn that the AIDS pandemic is still in “an early phase.” Infection rates are “climbing higher than previously believed possible,” and the effects in the worst-hit areas of the world are devastating.

“The vast majority of people living with HIV/AIDS worldwide are in the prime of their working lives,” explains a United Nations report. As a result, it is believed that several countries of southern Africa will lose between 10 percent and 20 percent of their work force by the year 2005. The report also says: “The average life expectancy in sub-Saharan Africa is currently 47 years. Without AIDS, it would have been 62 years.”

Efforts to find a vaccine have so far proved fruitless, and only 4 percent of the six million AIDS sufferers in the developing world receive drug therapy. At present, there is no cure for AIDS, and doctors fear that most people who are infected will eventually get the disease.

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T lymphocyte cells infected by the HIV virus

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A lab worker examines a challenging strain of virus

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CDC/Anthony Sanchez

A World Free From Disease

“All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country.”​—ALMA-ATA DECLARATION, SEPTEMBER 12, 1978.

TWENTY-FIVE years ago, primary health care for everyone on earth seemed to some to be an attainable goal. The delegates to the International Conference on Primary Health Care, meeting in Alma-Ata, in what is now Kazakhstan, resolved to have all mankind immunized against the major infectious diseases by the year 2000. They also hoped that by that same year, basic sanitation and safe water would be available to everyone on earth. All member states of the World Health Organization (WHO) signed the declaration.

The goal was certainly praiseworthy, but the follow-up has proved disappointing. Primary health care is by no means universal, and infectious diseases still threaten the health of billions of people on earth. And these fatal maladies often strike down children as well as adults in the prime of life.

Even the triple threat of AIDS, tuberculosis, and malaria has not compelled countries to “cooperate in a spirit of partnership.” The newly established Global Fund to Fight AIDS, Tuberculosis and Malaria asked governments for $13 billion to help curb these epidemics. By the summer of 2002, however, just over $2 billion had been offered​—in the same year, military spending reached an estimated $700 billion! Sadly, in today’s divided world, few threats are capable of uniting all nations for the common good.

Even with the best of intentions, health authorities find themselves handicapped in their fight against infectious diseases. Governments may not provide the necessary money. Microbes have become resistant to many drugs, and people may insist on pursuing a high-risk life-style. Furthermore, endemic problems such as poverty, war, and famine pave the way for pathogens successfully to invade millions of human hosts.