THE NEW EPIDEMICS

FLUSHED WITH RECENT VICTORIES OVER OUR DEADLIEST FOE, THE MICROBE, WE NO LONGER SEE OURSELVES AS ENGAGED IN A STRUGGLE FOR SURVIVAL. BUT IN TRUTH, A TASK FORCE OF MEDICAL DETECTIVES IS DISCOVERING, WE HAVE MERELY TRADED OLD EPIDEMICS FOR NEW ONES—AND EVEN THE OLD ONES SEEM TO BE COMING BACK IN NEW WAYS

ALAN PHILLIPS December 2 1961

THE NEW EPIDEMICS

FLUSHED WITH RECENT VICTORIES OVER OUR DEADLIEST FOE, THE MICROBE, WE NO LONGER SEE OURSELVES AS ENGAGED IN A STRUGGLE FOR SURVIVAL. BUT IN TRUTH, A TASK FORCE OF MEDICAL DETECTIVES IS DISCOVERING, WE HAVE MERELY TRADED OLD EPIDEMICS FOR NEW ONES—AND EVEN THE OLD ONES SEEM TO BE COMING BACK IN NEW WAYS

ALAN PHILLIPS December 2 1961

THE NEW EPIDEMICS

FLUSHED WITH RECENT VICTORIES OVER OUR DEADLIEST FOE, THE MICROBE, WE NO LONGER SEE OURSELVES AS ENGAGED IN A STRUGGLE FOR SURVIVAL. BUT IN TRUTH, A TASK FORCE OF MEDICAL DETECTIVES IS DISCOVERING, WE HAVE MERELY TRADED OLD EPIDEMICS FOR NEW ONES—AND EVEN THE OLD ONES SEEM TO BE COMING BACK IN NEW WAYS

ALAN PHILLIPS

LATE IN APRIL OF 1957 the telephone rang in a big bare-walled downtown Ottawa office where the federal epidemiologist and a staff of fourteen operate what they call a "radar service" to guard against invasion by our deadliest foe: the microbe.

It was their U. S. counterpart, the Communicable Disease Center in Atlanta, warning them that influenza had broken out of China. It looked like a new strain of group A flu virus (later confirmed and tagged A2) against which the world's population had no immunity. An epidemic seemed (and was) on its way.

The public reacted with fearless indifference and most doctors remained unperturbed. Flushed with recent victories over infectious bacteria, we no longer think of ourselves as engaged in a struggle for survival. We view nature's biological laws with detachment. Gone is our dread of her periodic purging. Epidemics? A relic of the prescientific past.

OPTIMISM: PASTEUR’S ACCIDENTAL LEGACY

In truth, says Dr. Edward Best, our federal epidemiologist, we have merely traded one set of epidemics for another. Smallpox is gone but hepatitis, a liver disease that can cause lifelong damage, is rampant. There are two types, infectious and serum. The first is out of control. It is spread by person-to-person contact and by contaminated food, water and milk. The

second, serum hepatitis, most embarrassingly, is spread by inoculation of human blood or serum, or by the use of syringes or needles contaminated w'ith traces of infected blood. Two percent of the patients receiving blood transfusions at Billings Hospital in Chicago get hepatitis. This is four times the rate of 1945, and since Billings is one of the best U. S. hospitals, the average rate is probably higher.

Cholera has vanished from Canada but the insidious staphylococcus organism is w idespread in our hospitals. It results in persistent pimples, boils, abscesses and pneumonia, one of the major causes of death during outbreaks of flu. Says Dr. David Kubryk of the Department of National Health and Welfare, "It's the big ignored infectious disease problem today.” Hospitals say little about it for fear of lawsuits.

Though typhoid is growing rarer, syphilis is increasing; already it has doubled since World War II. Dr. Arthur Guirdham, a British epidemiologist, says, "However successful we have been in our employment of the antibiotics and other methods of treatment, the total morbidity to which w'e are subject remains the same.”

Our excessive optimism about the final suppression of epidemics dates to the 1880s and Pasteur, whose five vaccines proved once and for all that disease was caused by microbes. They invade our w'orld in multitudes at every interstice: big microbes called protozoa, middle-

sized ones called bacteria, and viruses, protein particles on the borderline of life, unable to reproduce until they invade a living cell. They are in our water, air and earth, in our nose, mouth, throat and skin. They can scar us with pockmarks and warts, afflict us with fever, inflammation, deafness, blindness, sterility, paralysis and insanity. They may coexist in our bodies for years, then suddenly, inexplicably, a species multiplies, causing disease. By the movement of water, air. insects, animals or birds — for most microbes cannot move by themselves — these organisms scatter and w'c have an epidemic.

WE SURVIVE DIPHTHERIA TO DIE OF CANCER

The impact upon medicine of Pasteur's revelations, so exact, so scientific, was enormous. It took medicine out of the realm of art and into the laboratory. It has culminated this past decade in a deluge of “miracle” drugs, leading medicine, says Guirdham, to an impasse.

"As bacteria come under control the virus diseases advance,” says Best. "We survive diphtheria only to die of chronic disease” — mainly heart ailments and cancer, now' epidemic in North America, and suspected of being caused, at least in part, by virus infection.

All the genius of medical science has failed so far to produce a drug to curb the more than 200

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THE NEW EPIDEMICS

A2 was mild. It helped kill only 1,000 Canadians

known viruses. They are so small that one to twelve million measure only an inch; study is incredibly difficult. Says the eminent microbiologist, René Dubos, observing that man has learned to control all other creatures but these: “Except in a few situations, micro-organisms are today as undisciplined a force of nature as they were centuries ago.”

A similar and salutary pessimism was apparent in the action against A2 by our federal and provincial epidemiologists, those public health doctors who study and try to contain disease in the mass. They formed a control committee, sent for samples of the virus, and asked laboratories in Montreal and Toronto to make new vaccines. They set procedures in case the epidemic got out of hand, and priorities for immunization of hospital, fire and police personnel, sick persons, the aged, and pregnant women.

It does not seem in retrospect that they acted with undue caution. A2, though mild, prematurely disposed of perhaps a thousand Canadians. Its notorious predecessor in the great pandemic of 1918-19 had teamed tip with Pfeiffer’s bacillus to kill twenty-one million people, more than twice as many as were killed by World War I. “We were lucky this time,” Best says. A2 recruited no accomplices.

Some experts think that our flu pandemics every ten years or so are caused by mutation, or change, in the virus. But Dr. .1. Mulder of the World Health Organization has found antibodies of A2 in the blood of elderly Hollanders. Antibodies are the body’s defense against attack by microbes and Mulder’s discovery could mean that A2 caused the globegirdling outbreak of 1889-90. But if A2 is not a new, but forgotten strain, why did it become suddenly virulent? There is no answer.

We live with creatures as mysterious as life itself. Last year in February sixtyfive people fell ill in the same week from eating food contaminated by a new strain of bacteria. Salmonella Canada. It appeared simultaneously in B.C. and Ontario, spread rapidly through all provinces but three, then vanished.

“It’s a baffling epidemiological picture,” says Dr. Edward Bynoe, head of bacteriology in the National Health and Welfare department. “On the other hand, you have a beautiful pattern for Salmonella Heidelberg. Up to ’52 we never had a case in Canada. Suddenly it appeared in a flock of poultry in Alberta. We picked it up next in a butcher shop in Vancouver. You could follow it as it moved progressively east. Now it’s the commonest strain found here. Compare this with the Canada. Here’s something brand new in the world. It explodes in two widely separated places at once and then fades from the picture. Why? We haven’t a clue. Is it possible that Salmonella B, fairly common in Canada, has suddenly mutated, that something happened in the genes to form a new strain? We just don’t know.”

In the mid1800s, low-lying areas of Ontario were hotbeds of malaria, that treacherous tropical scourge that helped break the power of ancient Greece and still kills 1.500.000 people a year. It is caused by a protozoa injected by the bite of a species of mosquito called Anopheles.

“The species is present in patches all across Canada.” says Anthony Downes, a federal mosquito specialist. “But malaria is gone. It used to be in the south of

England and now there is none. It might be that a tiny climatic change has tipped the scale. Perhaps a series of hard winters knocked out the parasite; it may not be as adaptable to the cold as the mosquito. I don't know and I don't believe anyone else does. But we’re luckier than we know how to explain. A considerable number of people came back from the war with malaria but the Anopheles here haven't picked up the parasite.”

We are as much at the mercy of chance as ever. Scarlet fever, described by a medical optimist in 1701 as "this name of a disease, for it is nothing more.” came back in the 1800s and killed children like Hies. Recently, it has grown mild again. “And why?” asked Lord Holder, a distinguished British physician. "Seeing that we know as little about its causation or its treatment as we did when this form of disease was common."

"One no longer sees such fulminating cases of measles as formerly. " Dr. Guildham says. "Syphilis . . . presents a picture totally different from what it did even fifty years ago.” Tuberculosis lesions, he says, "are essentialy different in nature from those occurring two or three decades ago ... I believe these changes are more

independent of the treatment proffered than we care to admit."

The role of modern science, despite its startling achievements, "has not been so unique and its effectiveness not so complete as is commonly claimed," writes René Dubos. "In reality . . . many of the most terrifying microbial diseases— leprosy, plague, typhus and the sweating sickness, for example—had all but disappeared from Europe long before the advent of the germ theory."

“The discovery of micro-organisms did not solve the problems either of epidemics or the epidemic constitution." says Dr. John Gordon, a U. S. epidemiologist. "Indeed. it made them more difficult." It overthrew the 2,000-year-old theory of Hippocrates, father of medicine, that health lay in a harmonious, balanced life.

Epidemiologists are rediscovering Hippocrates. They speak of a balance between the host (man), the agent (the microbe) and environment. They speak of “multiple causation,” pointing out that disease-causing microbes are w;ith us always. For example, herbes simplex, the virus that causes cold sores, inhabits the skin around our lips but never causes blisters until we suffer chills or upset.

Florence Nightingale put it succinctly: “There arc no specific diseases; there are specific disease conditions." Not medical science but social reform — sanitationconquered the great filth plagues of the Middle Ages.

But old germs, like old soldiers, never die. "In the long continuous struggle between man and microbes we have not rid the world of a single pestilential disease,” says Dr. C. P. Stevick. a U. S. physician. Bubonic plague, the Black Death that in (he 14th Century wiped half of humanity

off the face of the earth, is hiding out with the wild rodents of our countryside.

It was this plague that gave us, in 1937. our first federal epidemiologist. A mink rancher in Alberta, who was feeding his mink on gophers, became ill while pelting mink dead of some unknown sickness. Four days later, en route to Calgary in an ambulance, he died. An official report later linked his death to plaguebearing gophers, and an epidemiologist was hired to probe the "plague menace.”

Plague is a rodent disease, common to gophers and wild mice, and undeveloped areas of British Columbia and Alberta are vast, ever-filled reservoirs of the bacilli. It is passed from animal to animal—and to man — by fleas. "What may happen — and this is the danger,” says Dr. J. A. McKiel. a federal expert on zoonoses, diseases that animals transmit to man. "is that man is building out into the countryside. 'I his may bring him into the plague area and the rats and mice that follow man may pick up the fleas from these wild infected mice. This has already happened in San Francisco and Washington State.”

Here we have the potential source of an epidemic. For while plague in its bubonic form is not passed from man to man, in its late, pneumonic form — if it reaches the lungs-—it is contagious. "That's the one that travels fast.” McKiel says, "that caused the great plagues of history.”

In New Mexico this summer two people died of plague contracted while tramping through the countryside. "As long as man doesn’t mess around in the animal’s habitat. everything’s fine.” says McKiel. "But as more and more people take up camping, coming closer to nature, man runs the risk of entering the chain of transmission." If man should relax his vigilance, plague could come back.

Yellow fever: still a great killer

We thought yellow fever was conquered in 1929. It had made the tropics the "white man's grave" till the Rockefeller Foundation cleared its carrier, the Aëdes acpypti mosquito, from almost all the Americas. Then an outbreak in 1932 dashed hope of completing the job. Not only man but monkeys, it was found, acted as host. The jungle remained an enormous pool of infection.

In 1949 yellow jack broke from its jungle barricade. It moved through the monkey population north across Panama at a steady pace of eleven or twelve miles a month. It was finally found to be carried this time by the Hacmopopus spcpaz.z.inii mosquito, traveling inaccessibly high in the jungle canopy, frying to predict its path, said Colonel Norman Filon of the U. S. Army Medical Corps, was like "trying to outguess an enemy possessing many secret weapons who keeps introducing one of them from time to time.” He predicted nevertheless that the virus would reach Mexico by 1957. He was right, ¡here it remains, still one of man's greatest killers.

The jungle may be the world’s great reservoir of virus disease, thinks Dr. Ottis Causey of the Rockefeller f oundation, who has trapped sixty unknown viruses in the Amazon—"viruses waiting for a disease,” he calls them. He thinks birds may carry these viruses to far-off northern lands where some, now harmless to man. could mutate and turn deadly.

In 1957 an Amazon hunter shot a seagull that had been banded a month before in Massachusetts. It is known that birds spread Japanese encephalitis, a brain inflammation, and Dr. Jordi Casals of the Rockefeller Foundation has noted that the migratory path of the gull lay directly over those U. S. regions that harbour

a similar virus, found also in Canada.

In July of 1929 several thousand Brazilian parrots were auctioned off in Cordoba, Argentina. Two months later, psittacosis, or parrot fever, a form of pneumonia, flared up in Buenos Aires, killing, among others, two actors in a play containing a parrot. It broke out next in Switzerland, then Germany. Poland. Austria, across Scandinavia and northern Africa. It reached here in 1930 and our government slapped an embargo on the importation of more than two alien parrots in one shipment.

But it was still such a rare disease that in 1933 the health officer of Toronto denied that an outbreak he labeled flu could possibly be parrot fever. "You'll have to prove to me that such a disease exists.” he said.

l'welve years later, a study on Long Island proved more than anyone expected. Half the area's pigeons carried the virus of parrot fever. Gulls were carriers, ducks, chickens, crows. Almost any bird can transmit psittacosis. It is far from rare nor is it as serious as doctors had

thought; they had been seeing only the serious cases. Undoubtedly many Canadians have had it and thought they had flu or pneumonia.

Birds are like typhoid carriers. They can carry the virus without showing symptoms till an upset like overcrowding starts the microbe multiplying. People catch it by breathing dust containing droppings from sick birds. Four years ago Dr. Best, now federal epidemiologist, investigated an outbreak on Vancouver Island that laid up twenty-three poultry plant workers. The virus was traced to a nearby turkey farm. "We wondered if they got it from gulls.” Best says.

I here are something like eighty diseases that birds and animals share with man. "Starting in the mid-twenties we got reports of a mysterious disease affecting Arctic foxes." says Dr. P. J. G. Plummer of the federal Animal Diseases Research Institute. "It spread to sled dogs and that was calamity. But we couldn't get any specimens—-they were putrid by the time they reached us. It was early '47 before

a report from Baker Lake came in at a time when I could get up and find out what it was.”

It was rabies, for centuries one of man’s most feared diseases, for unless vaccine is given before the virus incubates it moves inevitably and agonizingly over the nerveways to the brain, producing convulsions, paralysis and often, mercifully, delirium. Through roving wolves and coyotes it spread south to Alberta, then east. Gophers. picking it up. became venomous as rattlesnakes and more vicious. It is now in forty-two districts of Ontario. "What keeps it going is a puzzle," says Dr. G. E. Large, the Ontario epidemiologist. It is mainly in foxes, skunks, raccoons, and, most ominous, the bat.

Until last month Ontario doctors discounted the likelihood that our common insectand fruit-eating bats transmit rabies. though people in British C olumbia have been bitten. I he onl> true carrier, they pointed out. was Latin America's vampire bat. that blood-relishing horror of Gothic novels. Alone among creatures, as

far as we know, it may survive the virus.

Rabies, however, was rampant in 1955 among the millions of bats of Carlsbad Caverns. New Mexico, a great subterranean tourist attraction. A study revealed that these common insect-eaters wintered in Mexico, sharing the caves of the vampires. Here, obviously, is the link that leads up the seaboard states to Canada.

"Practically every state that borders on Canada now has rabies-infested bats,” says Dr. McKiel, the zoonoses expert. "We can safely assume they're in places in Canada other than B. C.” Three days after this comment a bat attacked a child near Barrie, Ontario.

Last month, another disclosure, most disconcerting of all, was made by a U. S. bat man, Dr. Denny Constantine. Tests for two summers with animals in the caves of common bats show that bat urine transmits the virus—and bats urinate as they fly overhead. This explains why two Americans died of rabies without being bitten. And it may help explain its puzzling sweep through the wilderness, now an impregnable stronghold for the virus. The best hope of control is a new vaccine, developed but not fully tested.

But even immunization—a hair of the dog that bit us, a small dose of disease germs to spur the body to make antibodies—may not be virus-proof. Doctors were sure that immunization gave lifetime protection against diphtheria, which shrunk from a leading cause of death in the mid-1800s to a rare disease in 1935. T hen, about 1944, it began to come back— among immunized teenagers.

The ‘"amazing conclusion,” says Dr. C. P. Stevick, a U. S. physician, is that ‘"by virtually eliminating diphtheria . . . we have lowered the general level of resistance. . . . For years people have been carrying undetected diphtheria bacilli in their throats without symptoms. . . . Frequent exposure to such carriers reimmunized older children and adults. . . .” Nature. in effect, had been giving us booster shots. Our campaign against the disease, Stevick says, "‘reduced the unrecognized carriers. Children were no longer exposed . . . and the early artificial immunity is no longer maintained by natural means. Diphtheria, on the verge of extinction, had struck back.”

Ironically, cleanliness, which is all that restrains infectious hepatitis, our newest national epidemic, prepares us for the ravages of polio. Polio as we know it did not exist before 1900. It was uncommon, a curiosity called infantile paralysis “largely restricted to children," says Dr. John R. Paul of Yale University, dean of authorities. “Today it's a dreaded scourge . . . more prone to attack older children. It showed up in countries with high standards of living. ...” Black, brown and yellow people are relatively free. Whites in South Africa suffer ten times more polio than the blacks.

" It's very much a disease of improved sanitation,” says Dr. David Kubryk of National Health and Welfare. “Exposure gave us natural immunity and the mother transferred her antibodies to her baby. It's only good for three or four months but if the baby ate polio viruses during that time it could acquire a lifelong immunity."

The cost of this natural immunity was one case of paralysis for every 200 people infected, most of whom probably thought they had a cold. But now', with Salk vaccine reducing exposure and natural immunity, "young parents run the extra risk,” says Paul, “of being infected by their children.” And when the virus strikes people with no immunity it is devastating. In 1949 it killed and crippled fifty-four percent of a group of isolated Hudson

Bay Eskimos. Our control measures, Paul warns, may merely postpone the disease until later in life when it is far more serious.

Similarly, our modern living conditions tend to check the spread of German measles, or rubella, once common and trifling in childhood. Now it skips many girl children with monstrous consequences later — if it strikes them in early pregnancy they have one chance in five of giving birth to a feeble-minded, blind or malformed child.

Since the virus has not been isolated "all we can do is hope,” says Kubryk. "that girls get rubella before they go to school. Maybe you read of our measles parties in Ottawa this year. If a child caught the measles the mothers were inviting other children to come and play with them” — a device suggested by the leading U. S. authority. Dr. Theodore In-

galls, who presumably read of the smallpox parties held in England two centuries ago.

Our vaunted control of disease is largely illusion. We give our TB campaigns credit for conquering the Great White Plague, but in the one hundred drugless years prior to 1945, the T B death rate feil from 500 deaths per 100,000 people to fifty. It w'as the great nineteenth-century epidemics, brought on by the sudden shift from farm to city, that gave to those they spared a high resistance. Latin American countries now starting their Industrial Revolution are suffering TB epidemics despite drugs.

New cases here are now so rare-—one in every 4,000 X-rays—that each costs thousands of dollars to find. But the cost of our lost immunity may boost the bill much higher. We had a warning in 1958. Into a rural district near Coaldale, Alberta, nearly freed of TB by active control, came a school bus operator who was tubercular.

The test that followed discovery sent eight children to the sanitorium. “In the children using his van,” a report read, “twenty percent were positive compared with just under three percent in the children throughout the entire area. This small

circumscribed epidemic may be the forerunner of many others. . . .”

How many such carriers are there? "A survey in Ontario last year,” Dr. Kubryk says, “showed that one in five active cases doesn’t go in the san. Another twentyfive percent leave before their treatment is finished. I call it absent without leave. That’s about 1,500 a year in Canada and maybe half are infectious. Well, that’s fantastic. Others leave and don’t carry on with their drugs.” In such cases the bacilli may develop resistance to the drug and the carrier will spread drug-resistant TB.

The overuse of antibiotics is developing drug-resistant strains of venereal disease organisms. Strains of staphylococcus resistant to penicillin are widespread in many of our hospitals. At times they may be infecting, says Dr. Kubryk, "up to seventy percent of the babies born” and "ten percent of the postoperative wounds.”

"Ask anyone in a medical ward if they have a problem with staph and they say, ‘Not much,’ ” Dr. Best says. "But they may have it all over the hospital — no one’s added up the infected cases as they occur in the different wards. It often appears only after the patient gets home. In infants it appears as little pustules like pimples. In mother it will appear as a draining breast abscess. In brother it may appear as a boil.”

Staph is classed as iatrogenic—“caused by the physician.” Resistant strains, says the British bacteriologist Ronald Hare, “are now present in the noses of a high proportion of the nursing and medical staffs of our large hospitals.” Control is almost impossible; there are twenty different strains.

Drugs may control one strain of microbe only to loose another. Around 1945 it was learned that penicillin killed the green streptococcus that causes subacute bacterial endocarditis, a fatal disease. But, Dr. Dubos says, “disappearance of the streptococcus was sometimes followed by infection of the heart valves with other kinds of bacteria normally present in the intestines or respiratory tract.” Man. in attempting to control his internal environment, is “probing in the dark.” says Best.

Even virulent microbes may confer unknown benefits. Sickle-cell anemia in Africa, though fatal to some Negro children, gives them resistance against malaria, much more widespread. In attempting to do away with biological adaptation "we are tempting fate,” says Dubos. "In the long run natural forces may be more effective than medical procedures."

The epidemiologist’s view is that microbes are part of man’s life and the germ theory of medicine, which treats them solely as enemies, is vastly oversimplified. Microbes devastate crops but they also make nitrates that nourish plant life. They manufacture poisons but they also synthesize vitamins. If sometimes we cannot live with them we can never live without them, and to look on them as the sole cause of disease, says the epidemiologist, is to take medicine up a blind alley.

“Health is a balance of forces,” says Best. “Our job is to find out what throws it off balance. Flow does air pollution affect lung cancer? What's the relationship of diet and heart disease?” Clearly the microbe by itself does not start an epidemic. As George Bernard Shaw once quipped, with disconcerting perception, “The characteristic microbe of a disease might be a symptom instead of a cause."

We cannot, probably should not, conquer microbes. That German pioneer in preventive medicine. Rudolf Virchow, stated it well in 1890: “Epidemics resemble great warnings from which a statesman in the grand style can read that a disturbance has taken place in the development of his people.” it