A Short History of Disease

by Sean Martin

  Belsen, initially a POW camp, had been designed to hold around 10,000 inmates. In 1943, its status had been changed to that of a concentration camp. Ironically, conditions were quite good by concentration camp standards to start with: there were no gas chambers, no forced labour. People got regular meals. Then, as Germany began to lose the war, the situation began to unravel. Belsen was designated an Erholungslager [Recovery Camp], where prisoners from other camps too sick to work were brought, although none received medical treatment. Over the course of 1944, more and more people were evacuated to Bergen-Belsen. Conditions, already bad, became even worse. Supplies of food and clean water ran low, and sanitation broke down. Although new arrivals were disinfected, in February 1945, the disinfecting process was abandoned, probably for want of supplies. Typhus quickly tore through the camp which, by then, held around 60,000 people. Among its victims was Anne Frank.

  As bulldozers dug mass graves in the main camp, a field hospital was set up at Belsen’s satellite camp a mile away. Typhus was the main problem, although tuberculosis, gangrene and various skin diseases also had to be treated. All the patients were severely malnourished, being little more than skin and bones. There was even evidence that some had resorted to cannibalism prior to the liberation. A shortage of equipment in the hospital caused constant problems with hygiene. Instruments could not be properly sterilised. 80 per cent of the patients had diarrhoea, and would attempt to get up in the middle of the night to relieve themselves. They would often be found dead in their own filth the next morning, ‘in all kinds of grotesque positions [that] reminded one nurse of the terrible stories told to her of the Black Death in the Middle Ages and the cries of “Bring out your dead!”’395 As nurses worked in conditions they had never imagined encountering, the last hut at Belsen’s main camp was burned to the ground on 21 May 1945 to stop the spread of disease.

  *

  By the time images of Bergen-Belsen were appearing in newspapers and on cinema screens, a vaccine for typhus had been in existence for several years. The story of its development was inextricably bound up with the Second World War.

  In 1928, French bacteriologist Charles Nicolle (1866–1936) was awarded the Nobel Prize for his discovery that the human body louse was the vector for typhus. Nicolle had made the discovery nearly twenty years earlier, when he had been the director of the Institut Pasteur in Tunis, noting that patients who were stripped, shaved and washed before entering the hospital didn’t go on to infect others. Although the louse is the vector, the disease is caused by the bacterium Rickettsia prowazekii, discovered in 1916 by the Brazilian Henrique da Rocha Lima (1879–1956), who named it after his colleague Stanislaus Josef Mathias von Prowazek (1875–1915), and the American Howard Taylor Ricketts (1871–1910), both of whom died of typhus while trying to find the cause of the disease. Rickettsia are microorganisms midway between bacteria and viruses. (Despite the similar names, rickettsia do not cause rickets, which is caused by vitamin D deficiency.)

  Typhus had been almost endemic on the Eastern Front during the First World War, as we’ve noted, but it was in Russia that the disease found its most fertile feeding grounds. As Arthur Allen remarks, ‘Typhus epidemics occur when a population is at the end of its tether. Starvation, cold, fear, and exhaustion are the normal prerequisites. Typhus corresponds with social collapse.’396 All of these elements were doing their work in Russia in the late nineteenth century, where typhus found an amenable home. The disease reached catastrophic proportions during the Revolution of 1917 and the subsequent civil war between reds and whites. Some twenty-five million Russians contracted typhus, and about three million died, possibly more.397 It was the worst outbreak of typhus in history. And then, with the disaster scarcely over, in the early 1930s typhus came back, ‘undoubtedly associated with the dislocations caused by Stalin’s industrialization and collectivization drives, and the ensuing famines.’398 Both under the tsars and the Bolsheviks, history had shown that typhus will rage ‘whenever human stupidity and brutality give it a chance.’399

  Charles Nicolle was unable to produce a vaccine, although it was not for want of trying. Polish bacteriologist Rudolf Weigl (1883–1957) continued the work at his laboratory in Lviv, Ukraine. Weigl managed to develop an effective vaccine by growing lice, injecting them with typhus and then grinding their guts into a paste. When the Nazis occupied the city, they forced Weigl to increase production of the vaccine for Wehrmacht troops, typhus still being a major problem on all sides in the conflict. Weigl told the Nazis he needed more human guinea pigs for his trials, and was able to save thousands of intellectuals and resistance fighters from deportation to the camps by getting them to take part in laboratory tests. Each person was required to become a human breeding ground for lice, which meant allowing hundreds of lice to crawl all over their legs and feed. (The lice were in cages attached to the legs, thus preventing them from venturing further afield.) Weigl then gave the Nazis a watered-down version of the vaccine which was not very effective, while sending the full-strength version to Jewish ghettos in Poland. Weigl’s former assistant Ludwik Fleck (1896–1961) did the same, although in far more precarious circumstances. A Jew, he was arrested and deported first to Lviv’s ghetto, and then to Auschwitz and finally Buchenwald. Far too valuable to be exterminated, Fleck was forced to work in the laboratories of both camps on typhus. The vaccine he produced pleased the Nazis, although it saved no lives. The vaccine Fleck had given them was a placebo.

  Meanwhile, in the USA, bacteriologist Herald R Cox had found a way to cultivate rickettsiae, a discovery that led to the manufacturing of a vaccine that was given to Allied troops when war broke out in 1939. Nobody wanted a repeat of what happened on the Eastern Front and in Russia. Dusting the body with the insecticide DDT (dichlorodiphenyltrichloroethane) also proved an efficient anti-typhoid measure. This was especially good news when it became clear that Cox’s vaccine wasn’t as good as initially thought: it didn’t completely prevent the disease, but merely ensured that the vaccinated person only got a milder form of typhus. The combination of the two procedures worked: among American troops, there were only 104 cases of typhus in the whole war, and no deaths.400 DDT also saw frontline action, being used to stop a typhus epidemic in Naples in the winter of 1943–4.

  Typhus is now treated with antibiotics, whose discovery and manufacture is perhaps the main stride forward against disease that occurred during World War II. It began with a story everyone heard at school: how Alexander Fleming came back to his laboratory after a summer holiday to find mould growing in one of his culture dishes. The mould had the ability to kill a number of pathogenic bacteria, and Fleming christened it penicillin, from its genus penicillium. Fleming published his findings in the British Journal of Experimental Pathology in 1929, but no one paid much attention to the would-be miracle drug. Unsure of how effective penicillin might be, and also of the practicalities of its manufacture, Fleming’s interest waned. The baton was then taken up by two scientists at the Radcliffe Infirmary in Oxford, Howard Florey and Ernst Chain. Together with Edward Abraham, Norman Heatley and others, they managed to isolate and concentrate penicillin. Owing to the privations of wartime, conditions in the lab were makeshift: cultures of penicillin had to be grown in bathtubs, buckets, milk churns, food tins and bed pans. With funding from the American and British governments, who were clearly aware of its use in wartime, the Oxford team were able to get penicillin massproduced by early 1942. With various pharmaceutical companies now involved, mass-production was ramped up in early 1944 in time for the Normandy Landings on 6 June, where antibiotics played a major role in saving the lives of Allied troops at an absolutely crucial moment in the war.

  *

  The discovery and development of antibiotics – of which penicillin was the first and most well-known – marked a turning point in humanity’s struggle with disease. The years immediately following the end of the Second World War were loud with pronouncements that echoed the Victorians in their optimism. US Secretary of State Geo
rge C Marshall declared in 1948, at the Fourth International Congress on Tropical Medicine and Malaria in Washington DC, ‘that the conquest of all infectious diseases was imminent.’401 The same year, the World Health Organization was founded to promote health and medical research around the globe. The concept of international cooperation to combat disease had taken its first hesitant step at the 1851 sanitation conference in Paris, when cholera was on the agenda. Now, with Marshall’s ambitious objectives on the table, international cooperation would be vital if some of them were to be achieved.

  (It’s no coincidence that George C Marshall also put his name to the Marshall Plan, another child of 1948, which was intended to spread American culture, values and industry across the world in the name of de-Nazification and post-war reconstruction. Its real aim, however, was not to make the world safe, but to make the world safe for America. As with Victorian campaigns against disease, which were inextricably bound up with imperialism and capitalism, so too was the post-war drive to eradicate disease. However, it wasn’t just the West that was optimistic in the battle against disease: the Chinese communist party ‘waged a peasant-based war on infectious diseases’ during the 1950s and 1960s.402)

  ‘For Western physicians, the 1950s and 1960s were a time of tremendous optimism’, Laurie Garrett notes. ‘Nearly every week the medical establishment declared another “miracle breakthrough” in humanity’s war with infectious disease.’403 It was the era in which ‘the end of’ a particular disease would be regularly trumpeted. Many of these breakthroughs were in the fields of vaccines and other treatments, making good on the discoveries of Fleming and the Oxford team. By 1965, more than 25,000 antibiotic drugs had been developed. ‘The term “miracle drug” entered the common vernacular.’404

  Among the triumphs was the development of a vaccine for polio. A disease whose provenance stretches at least as far back as ancient Egypt, when it appears to have been depicted on funerary stelae (see Chapter 2), polio became a major problem in the early twentieth century. The reasons for its sudden appearance as an epidemic, rather than endemic, disease are unknown.

  Poliomyelitis is a virus that, although asymptomatic in 90 to 95 per cent of cases, can cause paralysis, paresis and even death if the respiratory system is attacked. Quite why the disease progresses to these more serious stages in such a small percentage of cases still remains a matter for research. Polio derives its name from the Greek for ‘grey matter’ – a reference to the spinal cord, which can be seriously affected by the disease. It was first recognised as a ‘debility of the lower extremities’ by the British physician-apothecary Michael Underwood (1736–1820), followed by the German doctor Jacob von Heine (1800–79), who dubbed it ‘infantile spinal paralysis’; in 1908, the Austrian biologist Karl Landsteiner (1868–1943) discovered polio to be contagious. Following a few sporadic nineteenth century outbreaks (England, the USA and, of all places, St Helena, were affected in the 1830s), the worst epidemic occurred along the Eastern Seaboard of the USA in the summer of 1916. 9,000 cases were reported in New York City alone, almost all of which were children under five years of age. In the sort of mass panic we might more readily associate with Orson Welles’s later War of the Worlds radio broadcast, 50,000 children from New York and New Jersey were evacuated to the countryside in an attempt to stop the disease spreading further. Rumours spread that the disease had been started by Italian immigrants, causing riots. The rich fled to their summer homes, and schools were closed. Infected families were quarantined in their own homes, and in Hoboken, New Jersey, police rounded up stray children at train, subway and ferry stations. In all, the epidemic claimed around 6,000 lives across the country.

  As with cholera and typhoid, polio is a disease that flourishes in poverty-stricken urban neighbourhoods, being transmitted by unwashed hands or faecal contamination of drinking water (the faecaloral route). However, it was also able to strike the rich and well-todo: the most famous victim from Ivy League circles was future US president Franklin Delano Roosevelt, who contracted polio in 1921 at the age of 39. Again, no one is quite sure why this should be so, as FDR was clearly not living in a dirty tenement in Hell’s Kitchen when he was taken ill.

  One theory regarding polio’s ability to cross social boundaries was that, prior to the great late nineteenth and early twentieth century improvements in public health and hygiene, children had more or less become immune to polio, due to constant exposure to the virus over the course of centuries. And then, ironically, the great drive to improve public health and hygiene left children vulnerable to the virus once more.

  Various treatments were devised over the succeeding decades. These included hydrotherapy (favoured by FDR); the use of leg braces, which became closely associated with the disease; the Kenny regimen (a course of physical therapy devised by Australian nurse Elizabeth Kenny); and the development of the iron lung, first used to treat polio patients in 1928. These machines, although expensive to build and as cumbersome as a First World War tank, saved thousands of lives by enabling collapsed or otherwise disabled lungs to breathe using the process of negative pressure ventilation. The patient would be put into the iron lung flat on their back, leaving just the head visible. The British writer JG Farrell (1935–1979), himself an adult victim of polio, described the experience of being inserted into one of the machines in his novel The Lung (1965):

  Feeling as horizontal and as petrified as a stone crusader, Sands discovered with dismay that the fountain of joy spurting up in him so suddenly at those first, deep lungfuls of air had now subsided to virtually nothing. How much longer was he likely to be in the bloody thing? This was something about which he had not the faintest idea. Was one in an iron lung for a matter of days, or weeks, or years? He felt that he had already been in the lung for far too long… a matter of three minutes or so. And what if…? But he knew that he must abandon the future and remain always in the present, wobbling dangerously, as if it were a difficult and dangerous bicycle from which he was unable to dismount without the risk of total calamity.405

  The calamity Farrell feared began to be a thing of the past with the development of effective vaccines against polio in the 1950s and 60s, the first by American doctor Jonas Salk, and then a second by his rival, Albert Sabin, which could be administered orally. Salk was hailed a national hero in the USA at the unveiling of his vaccine on 12 April 1955. As BBC broadcaster Alastair Cooke reported at the time, ‘Nothing short of the overthrow of the Communist regime in the Soviet Union could bring such rejoicing to the hearts and homes in America as the historic announcement last Tuesday that the 166-year war against polio is almost certainly at an end.’406 Although the battle against polio did not end in 1955, the vaccination campaigns were extremely successful, a model of post-war public health policy in action: cases in North America and Western Europe dropped from 76,000 in 1955 to under 1,000 in 1967.407

  Two other campaigns were even more ambitious than the one to eradicate polio: the attempts to rid the world of malaria and smallpox. A campaign of pesticides and drugs was waged against malaria from 1955 onwards, and by 1970 the disease had at least been eradicated from most of Europe, North America, much of the Middle East and the coastal regions of the Mediterranean. But it proved ultimately impossible to rid the world of the disease: there were simply too many mosquitoes.

  The campaign against smallpox began at the request of the Soviet Union in 1958. The disease was endemic in many of the Soviet Asian republics and was killing around two million people across the world each year. The issue was discussed at the WHO, and received almost unanimous support. They had a head start, as there had been a vaccine since 1796 thanks to Edward Jenner, and the disease was also easy to diagnose. The fact that only humans are susceptible was a further factor that helped the projected eradication programme: there was no vector such as the ubiquitous mosquito to deal with. The campaign finally began under the auspices of the American doctor Donald Henderson in 1967, who headed the WHO’s Smallpox Eradication Unit. The various teams u
nder Henderson’s supervision were to administer millions of vaccinations over the next decade. They also set up a system for containing the disease. If an outbreak occurred, quarantine measures would be put in place to ring-fence the disease and thereby break the chain of infection. This was easier said than done, as it transpired that 95 per cent of cases of smallpox worldwide didn’t come to the attention of health authorities in the country affected, or to the WHO. This resulted in the occasional use of force to vaccinate people, with Henderson’s units operating more like special forces teams, breaking into people’s homes with the local police in order to make sure people were treated. In another instance, a WHO team had to forcibly vaccinate armed robbers in Bangladesh, who were spreading the disease in the course of their activities. Gunshots were exchanged before shots of vaccine. But the robbers surrendered.

  Such tactics were deemed necessary in what seemed to be an impossible task. War and religion frequently provided additional obstacles. Either teams could not get vaccines to war-torn areas, or religious observances prohibited treatment. Sometimes, as had happened with cholera, religious pilgrims spread the disease unwittingly. This was how Europe experienced its last outbreak of smallpox in 1972, when a pilgrim returning from Mecca brought it back to Yugoslavia. The last case reported anywhere occurred in Somalia in October 1977. Then, in December 1979, the WHO felt cautiously confident in believing that its work on smallpox was done.