Runaway Diseases: And the Human Hand behind Them

The only disease on Oldstone's list that is currently responsible for a significant share of the world's premature death toll is aids-the U.N. aids Programme in Geneva says that HIV, the aids virus, has infected more than 40 million people so far, 30 million of whom are alive today, and will have orphaned 40 million children by 2010. The real scourges today and probably well into the next century are not terribly vulnerable to vaccinology: malaria, tuberculosis, aids, childhood respiratory disease, infant measles, antibiotic-resistant bacterial diseases, cholera, dysentery. Moreover, the last six years have seen a resurgence in the former Soviet Union of vaccine-preventable diseases that Oldstone declares controlled or nearly eradicated: diphtheria, whooping cough, typhoid fever, and polio. Epidemics of other vaccine- preventable disease have broken out all over the globe in the 1990s- notably, the West African meningococcal meningitis pandemic of 1996-97. These outbreaks point up the main problem with vaccines: invention is one thing, timely and proper use quite another.

Scientific discovery is only step one. Next, and more difficult, is appropriate disease prevention and distribution of the vaccine. On that point Watts has much to say in Epidemics and History: Disease, Power, and Imperialism. For failing to develop a vaccine or a cure for HIV, Watts denounces Western scientists as "incompetent braggarts, parading under false colors." He grudgingly applauds the World Health Organization's eradication of smallpox in 1977, but immediately adds that "niches emptied are soon refilled" and children killed by other microbes.

RAGE OF THE SOUTH

Watts blames Europeans for most of the world's infectious disease problem. Although plague killed large numbers of people on the steppes and in the cities of Central Asia well before it got to Europe, Watts' analysis picks up only with its arrival in Italy in 1346. However, he presents what is arguably one of the best portrayals of life in Europe and the Islamic world during the medieval Great Plague, focusing on the social, religious, and political activities that spread the disease, and on the economic fallout.

Similarly, he chronicles in rich detail the fourteenth-century European campaigns against leprosy, the use of disease as a tool of conquest in the Americas, the role of slavery in the spread of microbes, blatantly racist colonial practices in India and Africa that assumed indigenous populations were genetically inferior and so would not benefit from medical treatment, and Britain's often bizarre notions of cholera control during the Raj in India. Far less convincing are his assertions that the European syphilis epidemic of the seventeenth through nineteenth centuries resulted from Christian opposition to masturbation; that malaria may not have been indigenous to Africa; that French development policies spread yellow fever across West Africa; that smallpox inoculation was invented not by Britain's Edward Jenner but centuries earlier by African villagers. Yet Watts offers solid, stunning examples of Western idiocy that created superhighways for once-obscure microbes, leading to horrendous epidemics. His descriptions of the devastation, sometimes extinction, that European disease brought on the peoples of Mesoamerica after 1492 are emotionally difficult to read. Watts' rage seems reasonable in a historical context, but becomes less well grounded as he nears late-twentieth-century developments. Nevertheless, his is a perspective that Western, particularly Caucasian, policymakers would do well to comprehend.

Clearly there is need for a middle ground that allows candid communication between North and South, scientists and historians, empiricists and social activists. Science alone cannot defeat any emerging disease. Nor does the rage of the South advance its cause, no matter how justified by the historical record and current Northern practices-for example, the apparent unwillingness to find cost-effective ways to share expensive anti-HIV treatments with the estimated 26 million infected poor of the world.

All sides should remember the crucial lesson of Zaire's two Ebola epidemics: it is impossible to anticipate or prevent isolated cases of infection, but outbreaks and epidemics require an amplifier. And this is almost always an event created by, and under the control of, human beings. E. coli 0157:H7, a potentially lethal mutant form of the ubiquitous bacterium, has been amplified by modern livestock and meat processing practices. In recent years hepatitis C has come out of obscurity to become one of the world's leading diseases and killers; the amplifier is use of nonsterile syringes. Typhoid fever became epidemic last year in Tajikistan, claiming at least 22,000 lives, because of the collapse of water and sewage infrastructures after Moscow's withdrawal and the ensuing civil war. In Asia and Eastern Europe, HIV is exploding because of the international traffic in prostitution and the slave trade in women.

Oldstone makes the fatal mistake of ignoring the amplifiers. Watts details their role in history, but by way of finger-pointing at Europeans. After all, when the Ebola virus emerged in Kikwit in 1995, the amplifier was Zairean corruption and public health collapse, driven by hospital workers-African hospital workers-who failed to respect the most minimal health standards. As dispassionately as possible, international health policy should concentrate on the amplification phases of epidemics-whether the amplifier is European or African, Northern or Southern-as the most cost-effective place to stop microbial culprits.