In the wake of Richard Preston's 1994 thriller The Hot Zone, a best-seller in 26 countries, the publishing industry has released a torrent of books about emerging disease threats. Nearly every major fighter of the Ebola virus has published a memoir, several scientists have produced warning missives, and fiction writers from Stephen King to Tom Clancy have made microbes prominent plot devices.
Amid the plethora of paranoia-inducing publications, barely a handful offer insights that could guide public policy, particularly from a global point of view. And practically speaking, the only relevant point of view for microbial issues is global, since bacteria, parasites, and viruses exploit appropriate ecospheres wherever they find them, regardless of national boundaries.
Despite the chatter on everything from "mad cow disease" to mutant strains of the Ebola virus, there are serious causes for concern. The Clinton administration has formally designated emerging infectious diseases as a national security issue. That has drawn big political players such as the CIA, the National Security Council, the Defense and State Departments, and the U.S. Agency for International Development into an arena that before the mid-1990s was the province of scientists.
The most recent entrants in the debate on emerging diseases are the historian Sheldon Watts of American University in Cairo and the virologist Michael Oldstone of the Scripps Research Institute in La Jolla, California. Watts, who has spent his career in Nigeria and Egypt, sees humanity's relations with the microbes from the side of the victims of European imperialism. In his analysis-which is indebted to William McNeill's 1976 landmark Plagues and Peoples-most of the scourges of the last millennium are direct results of Christian or European cultural and colonial practices. In contrast, Oldstone, a prominent American laboratory scientist, pays only cursory attention to the socioeconomic foundations of disease transmission, focusing his optimistic work on the triumphs of Western science. His book consciously emulates Paul De Kruif's gem, Microbe Hunters, although it is not nearly as strong.
Both Watts' and Oldstone's books leave a great deal to be desired, although their shortcomings are different. Watts is didactic, while Oldstone condescends. As for content, it is doubtful the authors could find much on the subject on which they could agree. Of the two, Watts sounds the more profound challenge to contemporary health policy. His perspective is stridently anti-development, anticolonialist, and critical of Christianity. In temper it resembles much of the writing by contemporary African intellectuals. And as is typical of that body of work, it draws from an awesome trove of historical evidence. Watts' scouring of Europe's and the Islamic world's ancient databases has resulted in a demanding work that compels readers to take his southern hemisphere-centric arguments seriously.
THE LIMITS OF MEDICAL SCIENCE
The bulk of the world's remaining literature on infectious disease, including Oldstone's Viruses, Plagues, and History, has a highly American or European point of view. "The obliteration of diseases," Oldstone writes, " . . . is a regal yardstick of civilization's success, and those who accomplish that task will be among the true navigators of a brave new world." The way to reach that world, he believes, is primarily through development of a broader range of vaccines, particularly against HIV (his personal area of research). That will require "the best efforts of scientists in medical research . . . not inhibited by political or religious interests, but supported by the full resources of governments and industry with conscientious participation by the general public worldwide."
Unfortunately, Oldstone doesn't discuss the enormous economic and legal barriers to vaccine production. With fewer than a dozen companies still in the business, and with the current profits for all vaccine sales combined less than those for a single patented anti-ulcer drug, there is little corporate interest in developing products that target diseases found mainly in poor countries. Moreover, consumer litigation so envelops the industry in the industrialized nations that budgets must include as much money for legal defense and insurance as for actual vaccine distribution.
Oldstone's heroes are the giants of vaccinology, and of the eight he discusses at length, only Carlos Finlay, a Cuban, was from the South. The history Oldstone recounts is one of scientific inquiry and success of men from the North, often in response to diseases that arose in the South. The social factors that turn sporadic cases of disease into epidemics are noted only in passing, usually drawing on nineteenth-century North American examples.
Western science, Oldstone argues, has triumphed over the world's biggest infectious killers, and there are only five significant foes left: aids, Lassa fever, the diseases caused by the hemorrhagic fever viruses (such as Ebola), mad cow disease, and hantaviruses. It's a curious list, for the first four are amenable to well-understood preventive measures (in order: condoms and clean syringes, rat control, sterile hospital and funeral procedures, and proper livestock and meat production practices). Further, Lassa can be cured with proper use of the antiviral drug ribavirin.
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.