Old and New Infectious Diseases Trigger Global Struggle
The day’s casualties sit listless on a stone bench, a handkerchief or crumpled corner of sari clutched to their mouths, feeble shields for a fearsome plague called tuberculosis.
“Ten years back, 40 to 60 outpatients would come in every day,” said TB specialist Yallappa Lakshman. “Now it’s 100. . . . And for five years we’ve been getting drug-resistant TB,” bacteria that defy proven drugs.
Lakshman’s SDS Sanitarium, in the front line of the fight against disease in southern India, is overflowing. But for all the misery huddled in its halls, it is just one small outpost in a global struggle between modern medicine and a plague of plagues--the comeback by infectious diseases.
Some are new, some “reemergent” like TB, and they have the world’s health establishment on the defensive, groping for resources, leadership, words.
The words are often of war.
“I compare them to guerrilla fighters,” senior Indian pathologist Vulimiri Ramalingaswami said of the microbes. “They wait for an opportunity to strike, like guerrillas.”
The opportunities come more and more frequently these days.
A U.S. government task force reports that at least 29 previously unknown diseases, such as the Ebola virus and AIDS, have appeared since 1973 around the world. At the same time, 20 well known ones have reemerged, including cholera, yellow fever and malaria.
Smallpox has been eradicated and a few diseases are in decline, but other microbes are showing “extraordinary resilience,” the U.S. experts said. And defenders like Lakshman are not always getting the weapons they need. Politics, profits and bureaucracy often stand in the way.
Behind the resurgence in infectious disease lies a complex of causes.
Some are obvious: The growing density of Third World “megacities” favors contagions like the deadly lung disease tuberculosis, spread through close contact. The growing ease of travel quickly spreads infectious agents, like the AIDS virus, around the world.
Some causes are less clear: Man’s encroachment on nature may be stirring up lethal microbes. Experts theorize that Ebola emerged from the African wilderness, via an animal carrier, when man cut too deeply into the forest.
And some causes are microscopic: Virulent bacteria, bent on survival like any organism, are rapidly mutating to forms beyond the reach of today’s antibiotics, sometimes helped along by misuse of the drugs.
Joshua Lederberg discovered the secrets of those mutations as a young researcher. Half a century later, the Nobel Prize-winning geneticist sounds an ominous note.
“I see this as a race that will be settled in 50 years,” Lederberg said at New York’s Rockefeller University. “It’ll either be our technology or it will be the evolution of the germ world that will have established its ascendancy.”
Some signs of germs ascendant:
* One after another, drugs that once cured malaria are being foiled by the mosquito-borne parasite. Its “changing coat” of mutations baffles scientists.
* Reported cases of tuberculosis worldwide rose by almost one-third between the mid-1980s and early 1990s.
* Hemorrhagic dengue, another mosquito fever, has struck in India, Africa and parts of Latin America for the first time in at least half a century. In October, it reached Texas.
* The U.S. death rate from infectious diseases rose 58% between 1980 and 1992. Even without AIDS, the prime factor, it rose 22%.
* An Asian strain of cholera reached Latin America in 1991 and at least 1.3 million people have been stricken since. And plague, dormant in India for a generation, resurfaced in 1994.
“Our surveillance mechanisms failed on the plague. Actually, they did not exist in that area,” said K.K. Datta, director of India’s National Institute of Communicable Diseases.
That is another, overarching cause cited for the comeback of contagions: Global successes against infectious disease in the 1950s and 1960s led to complacency, budget rollbacks and diversion of resources to heart disease and cancer.
The World Health Organization cites a “general weakening” of surveillance and other public health activities worldwide.
A chilling example came in 1995, when deadly Ebola hemorrhagic fever broke out in Kikwit, Zaire. It was four months before national health authorities were informed of the spreading disease, and more delays ensued when a Belgian lab where blood samples were sent proved no longer capable of doing the analysis.
Weak links produce a weak global chain.
“When a cluster of cases of new disease occurs in a remote part of Africa, eastern Europe, Asia or the Americas, the international community may or may not learn about it,” the U.S. task force complained.
WHO acted in October to strengthen the chain, establishing a division for emerging diseases with responsibility for mobilizing rapid-response teams for movement within 24 hours to infectious hot spots worldwide.
In an interview in Geneva, the division’s new chief, David Heymann, said he plans to bolster Third World labs with testing supplies, equipment and training. He also wants to tie WHO’s more than 200 collaborating centers together electronically.
“The Internet will bring a very old institution into the 21st century,” he said.
But the task will be formidable--and expensive. As Datta said in New Delhi, not only doesn’t his Indian center have an Internet link, but it doesn’t even get timely health reports from across this nation of 900 million people.
“We’ve proposed to the government that whatever lab information is generated should be linked up by e-mail or satellite, so I can know how many cases of polio are operating in Hyderabad or wherever, so I can advise the Health Department something is going on,” he said. The Indian government is looking for the funds.
It may be looking for a while. WHO, like other U.N. bodies, is in a budget crisis. The U.S. government, demanding additional WHO management reforms, has withheld $211 million it owes the health organization for 1995-96--one-quarter of WHO’s budget.
In other ways, too, the war on infectious disease bogs down in economics and politics.
Pharmaceutical companies show little interest in developing new drugs to help people on the margin--those stricken by microbes newly resistant to old antibiotics.
“There may be only 100,000 people whose life or death depends on a new antibiotic,” said Rockefeller University’s Lederberg. “That’s an enormous toll on one level, but not enough for an industry that measures its market in tens of millions of prescriptions.”
Industry spokesmen acknowledge that the research focus has shifted away from infectious diseases.
In antibiotics, “the easy hits already have been hit, the easy discoveries made,” said John Siegfried of the U.S. Pharmaceutical Manufacturers Assn. “It’s a more difficult field now to get results in, more and more expensive.”
On the political side, national sensitivities can thwart the microbe hunters.
Governments sometimes suppress reports on epidemics to avoid what happened to India after the 1994 plague outbreak--national panic and international isolation that may have cost the economy $1.5 billion.
To lessen the stigma attached to plague, cholera and yellow fever, the three diseases that must be reported, WHO is rewriting its reporting rules to drop the disease names and require only that symptoms be reported.
The politics reaches down to the grass roots too.
WHO warns that India faces a “time bomb” of drug-resistant tuberculosis. But TB specialists face resistance themselves.
“We make recommendations to the state governments,” said Bhaurao T. Uke, director of the National Tuberculosis Institute in Bangalore. “We tell them too few cases are being diagnosed, your treatment activities are weak, your reporting is poor. But they fail to act. Their priorities are different.”
Day in, day out, from his cramped office at the SDS Sanitarium, Lakshman sees the problems at ground level. Government drug supplies run short, and patients are forced to buy their own--at the equivalent of 75 cents a day.
“For a laborer, for them to spend this kind of money, it is not possible,” the doctor said.
They drop out of treatment. Their afflicted lungs deteriorate. And the halfhearted drug treatment has given another batch of TB bacilli the time and space to mutate into resistant forms.
Growing drug resistance threatens a TB plague of “unimaginable proportions,” unless richer nations pour $100 million a year into Third World anti-TB programs, WHO says.
Few expect to see that kind of generosity.
“The methodology and technology is available,” Uke said. “But the financial support is not there.”
The same could be said for malaria, cholera and other communicable diseases on the rebound as the 20th century nears its end.
“Once we thought one disease after another would fall,” Ramalingaswami recalled of the post-World War II years.
The 75-year-old dean of Indian pathologists mused about the fact that the scientific world recently marked the centenary of Louis Pasteur’s death. What would the “father of microbiology” think today?
“First, he’d be amazed at the tools science has developed,” Ramalingaswami said. “Then I think he might say, ‘You fellows have not acted promptly enough to use those tools. . . . You’ve allowed the bugs to get away.’ ”
