The mirage of health.
Environmental health (Social aspects)
Human beings (Influence on nature)
Human beings (Health aspects)
|Author:||Flannery, Maura C.|
|Publication:||Name: The American Biology Teacher Publisher: National Association of Biology Teachers Audience: Academic; Professional Format: Magazine/Journal Subject: Biological sciences; Education Copyright: COPYRIGHT 2009 National Association of Biology Teachers ISSN: 0002-7685|
|Issue:||Date: Nov-Dec, 2009 Source Volume: 71 Source Issue: 9|
|Topic:||NamedWork: Mirage of Health (Nonfiction work) Event Code: 290 Public affairs|
|Product:||Product Code: 8000144 Environmental Health Programs NAICS Code: 621999 All Other Miscellaneous Ambulatory Health Care Services|
|Persons:||Named Person: Dubos, Rene J.|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
I am writing this column in late August, so it's difficult to
predict what the H1N1 flu situation will be by like the time it is
published towards the end of the year. Since there is already a
pandemic, the spread of the virus will likely have picked up more steam
by that time, but how much steam it is difficult to forecast So I'm
not even going to try. Instead, I will make a prognostication that is a
safer bet: there will continue to be health issues of some kind at the
end of this year, at the end of this century, and on to the end of this
millennium. I am using as my crystal ball a book by Rene Dubos
(1901-1982) called Mirage of Health (1959). It seems appropriate to
examine this book on the fiftieth anniversary of its publication,
because it is at least as relevant today as it was at the time it came
out. Also, since this issue of ABT is devoted to health and medicine,
this work is a great reminder of the limits of the latter to ensure the
The book's main argument is that, as the title suggests, the quest for perfect health is an unending one, just as walking towards a mirage is a fruitless task. Dubos contends that the idea that better days are coming, that if we get rid of the latest scourge to health, life will be wonderful and we will to a ripe old age in good health, just isn't going to happen. In other words, finding the "cure" for cancer or HIV infections or ... isn't going to make life wonderful. He cites as support for his view the fact that finding a cure for tuberculosis (TB), the scourge of the 19th century, did not lead to a health utopia. In fact, thanks to life style changes rather than medical advances, the incidence of TB had already decreased significantly even before an antibiotic treatment for this bacterial infection became available in the 1950s.
I have been reminded of Dubos's book frequently over the years since I first read it in the 1970s. Most particularly, it came to mind in the 1980s when HIV and then Ebola virus entered our consciousness. For those who don't remember these times, both infections came as rather a shock to the American public who had become accustomed to the idea that infectious disease was no longer fatal. To put it very simply, bacterial infections could be treated with antibiotics and viral diseases prevented with vaccines. Then AIDS arrived, an infectious, incurable and in those early years, almost inevitably fatal, disease. This was not something we were prepared for because many of us, the baby boomers who had swelled the population, had never experienced the years when bacterial pneumonia was dangerously common and a bad cut could lead to an uncontrollable infection.
How could Dubos have been so prescient when most Americans were shocked by this onslaught and the others to follow? First of all, he was a microbiologist. He was already aware, more than most people of the time, that bacteria were developing resistance to antibiotics, that the reign of these drugs was likely to be short-lived and could only be extended by human ingenuity working to keep one step ahead of the microbes. Dubos was born and educated in France at the beginning of the 20th century, when French microbiology was still very much under the sway of Louis Pasteur's intellectual heritage. He came to the United States and spent most of his career as a researcher at what is now Rockefeller University in New York. There he discovered gramicidin, the first clinically tested antibiotic. While it didn't prove to be an effective drug, Dubos's research did yield useful information on antibiotic dynamics both in culture and in living organisms. When penicillin was discovered and being developed as a drug, he was involved in the early work done in the United States. He also did research on tuberculosis and pneumonia.
It was Dubos's studies on how bacteria became resistant to the effects of antibiotics that led him to consider the theme of health as a mirage. By this time, in addition to his journal articles, Dubos had already published two books for the general reader: a biography of Pasteur (1950) and a book on tuberculosis (1952). In midlife, he had discovered his gift for communication and went on to publish over a dozen more books, including So Human an Animal (1968) for which he received the Pulitzer Prize. The subtitle for The Mirage of Health is Utopias, Progress and Biological Change, and Dubos addresses the question of health from each of these three perspectives. He came from a European tradition of deep and broad learning; he was well-versed in history so he situates his argument in terms of past efforts to improve health. He describes why any hope that persistent efforts will lead to a future without disease are hardly of recent origin, though attempts to achieve this goal may have been of very different kinds in the past. Ponce de Leon's search for the fountain of youth was one manifestation of this predilection because youth and health are obviously related to each other as are old age and illness. Others saw such utopias as existing in unspoiled parts of the world, such as the islands of the South Pacific, where civilization had yet to intrude. The link between civilized life and problems was emphasized by Rousseau who saw a move back to nature as the cure no only for physical but social ills.
Balance and the Environment
Dubos also goes further back in history to the time of the ancient Greeks and of course, to Hippocrates who considered health a result of balance in the body and ill-health to a disruption of that balance, due to too much or too little of one of the four basic humors or fluids in the body: black bile, yellow bile, phlegm, and blood. This idea of health as balance continued to be an important theme in approaches to keeping people well and is still significant today. We are warned not to: not eat too much or too little, not to over exercise but to exercise "enough," not to loaf or work too hard, etc. Hippocrates saw the environment in which a person lived as important to balance, so there needed to be equilibrium in interactions with nature as well as within the human being. Others saw illness in more specific terms, with different illnesses having different causes and resulting in different problems within the body, what came to be called the "specific etiology" view of disease. This is obviously the dominant opinion in medicine today, and Dubos traces its development and its consequences, focusing on medical approaches to, not surprisingly, infectious disease, especially in the 19th century. This was when microbiology was beginning as a science, when Koch, Pasteur, and others were identifying specific organisms as the cause of specific kinds of illnesses. But this cause-and-effect relationship was not always clear-cut and many in the field questioned it. They argued that diseases such as tuberculosis and cholera were not the result of invisible organisms but rather of the conditions of life.
It was well-known that those who lived in poverty were more likely to suffer and die from these diseases. Elie Metchnikoff, a leading microbiologist of his day who was appointed to the Pasteur Institute by Pasteur himself, was of the view that environment was the real cause of disease. To prove this in the case of cholera, he drank a solution containing a large number of these bacteria, yet he didn't contract the disease. Of course, Pasteur's own work countered this view. He had found that cultures of chicken cholera could be used to infect other chickens, and the same was true for anthrax and rabies.
This apparently fundamental difference in results is a good example of why research is difficult to do and why significant questions can remain unresolved for long periods. As we know today, specific infectious organisms cause specific symptoms, but there are usually several environmental factors involved in the spread of disease. One of the reasons H1N1 flu spread so quickly is because of air travel. As the epidemic took off in Mexico, the first cases in the United States were not in a border state like Texas, but in New York, at a high school about half a mile from where I work. Why? Because several students in the school had spent their spring break in Cancun, Mexico. The spread of HIV was slower and more stealthy, but again, an infection that arose in Africa soon had toeholds in the United States and Haiti-and then beyond-because of the ease of international travel.
In early centuries, travel was slower, but still a factor in the spread of infection. There is good evidence, though it doesn't convince everyone, that syphilis originated in the New World and didn't reach Europe until the Age of Discovery (Hendrick, 2002). Years ago, the historian William McNeill (1976) wrote a comprehensive work called Plagues and Peoples in which he argued that infectious disease had a great influence on the course of history. The decimation of Napoleon's army in Russia is just one example, and others stretch much farther back in time. McNeill contends that diseases like bubonic plague came into Europe with invading armies from the east in medieval times. Wars also lead to the kinds of conditions-poor sanitation, large numbers of people living in close quarters, famine-that create the perfect environment for the spread of infection. Dubos makes the same case in his book, though in lesser detail, and he cites Hans Zinsser's Rats, Lice and History (1935) where Zinsser, another microbiologist, charts the history of typhus, very convincingly presenting evidence that this infection is transmitted by lice on rats. Yet typhus looks like an environmental disease because it is so often found in areas of social and political turmoil. Such upheavals include not only wars and revolutions, but also floods, earthquakes, and other natural disasters.
However, Dubos looks at the other side of the coin as well and examines the social and political environments which lead to health improvements. He argues that tuberculosis, bacterial pneumonia, and cholera had become much less lethal in the 19th century, well before the discovery of the specific etiologies of these infections. Better sanitation and improved living conditions were responsible for this improvement. When I first read this, it really impressed me, and I have emphasized this when presenting infectious disease topic to students. Pasteur and his successors did a very good job of indoctrinating the public with the idea that if the infectious agent is removed so is the disease. But it makes a big difference when that removal takes place-before or after an individual is infected. Drugs may lessen the effects of infections, but it's better not to get them.
Dubos was looking at the other side of the coin, preventing contact with infectious organisms, when he argued that environmental change was such a powerful force for better health. It was in the 19th century that sewage systems were installed in European and American cities, thus separating waste water from drinking water and keeping people from a significant infection source. Today, childhood diarrhea is still one of the major causes of death in many parts of the world because such basic sanitation is still lacking over large areas. But it was more than just sewers that led to improved health in the 19th century; it was also a general rise in the standard of living. People had more money to spend on food, so they ate better and thus were in better shape physically to fight infection. They were also better able to heat their homes. In the United States, we take central heating for granted today, but this was a luxury for many well into the 20th century. We think of heat in terms of comfort, yet it also makes us a lot healthier. First of all, energy that would have to go to staying warm can be used to strengthen the immune system, and also, warm air is easier on the lungs, making for healthier respiratory systems. It is no coincidence that "colds" have that name. Dubos also credits public health efforts and social reformers for creating living and working conditions that put less stress on the body and led to a healthier population. These factors made tuberculosis less dangerous and dreaded while the only "cure" remained rest and living in an environment with clean air.
Yes, people still died of tuberculosis into the 1950s, when antibiotics were discovered to clear the body of the bacillus that caused this disease. However, people still die of TB today because there are strains resistant to standard treatments. As Dubos suggested, the idea of perfect health remains a mirage. Yes, the World Health Organization was able to rid the earth of smallpox in the 1970s, however, that is still a singular triumph. The aim has been to do the same for polio, but just recently, I saw an article on a major setback to this effort (Roberts, 2009). While type 1 and 3 poliovirus remain at large, type 2 had been wiped out throughout the world by 1999. It's now back causing infections in Africa. This year 124 cases of type 2 paralysis had been reported by July-four times more than last year. Its source is the weakened form of the virus found in the live vaccine used to eradicate the disease. Here is one of those catch-22 situations in public health, and one of the reasons why ridding the world of polio is still a tantalizing mirage. In other words, every effort to improve health has its unwanted, and often unexpected consequences: a live-virus vaccine is easy to administer, but can lead to reversion of the virus to a virulent form; antibiotics can trigger allergies and resistance; mammograms mean exposure to cancer-causing radiation; surgical procedures, no matter how simple, can go wrong. I'm stating the obvious here, but especially as the nation tries to deal politically with its healthcare problems, Dubos's viewpoint bears investigation.
I don't think good healthcare is the be-all and end-all for a good quality of life. I have some experience in facing realities, and I myself have had to choose between the best health care and the most use>friendly and I chose the latter. Sometimes health has little to do with healthcare. I just read an article about research showing that friendship is a major factor in health and that not all friendships have a positive effect (Couzin, 2009). Research on social networks indicates that people who smoke tend to be friendly with other smokers (all you have to do is stand outside an office building to know this is true). Smokers aren't just being sociable, they are also encouraging each other's unhealthy behaviors. The overweight tend to find each other as well, perhaps because they feel less guilty about having dessert at lunch when their friend is also ready for pie.
This research originally came out of that grand-daddy of longitudinal health investigations, the Framingham Heart Study which began in 1948. Nicholas Christakis and James Fowler of the University of California, San Diego took advantage of one question recorded on the charts of the 15,000 participants: Name a close friend who can find you in case we can't. They tracked down information on the long-term health of the participants and their contacts, finding that "every facet of health examined so far appears to 'spread' from person to person" (p. 454). These facets include smoking, obesity, happiness, unhappiness, and alcoholism. The researchers are criticized both for just stating the obvious and also for overstating the importance of their results. But findings are at the very least interesting, and bring up still another factor in healthiness and illness.
There is also other work suggesting that creating positive social networks can improve health. Lisa Berkman is an epidemiologist who studies social isolation's health consequences. In the 1980s, she found that those who tended to be less social also were more likely to die over the next seven years. Since social isolation is often related to risky behaviors like drug or alcohol abuse, this was not surprising, but even when such factors were ruled out, the risk was still over twice as high for the less social. This result has been replicated many times, but when Berkman tried various interventions to encourage social interactions among patients, the outcomes weren't always positive, perhaps because by the time these individuals were identified, their health problems were irreversible.
Berkman's work is reminiscent of those studies showing that having a pet increases mental and physical well-being. (Fly is lying--asleep of course--near my desk right now as a reminder of this, and I had a good report at my annual check up this week. What more research has to be done on this connection!) That something as simple as a phone call--or lick on the face--could improve health is indicative of Dubos's main argument, that health involves more than medicine, so conversely, medicine can't be looked upon as the savior that will bring perfect health. Let's face it, the human body isn't perfect and it gets less perfect with age-even dog owners die, eventually. But compared to some of the trends in medical research today, these social interventions seem simple and powerful.
The Consequences of Medical Science
Yet despite all this evidence, medical science is still looked to as the source of better health in the future. To mention a few areas of research receiving attention: there's work on rapamycin, a drug that significantly extends the life of mice, and some see as a possible anti-aging drug for humans (Kaeberlein & Kennedy, 2009); brain-implantable devices for the deaf and the blind (Clausen, 2009); reprogramming of cells as a way to create stem cells to treat particular disorders from Parkinson's disease to paralysis (Vogel, 2008). These are all exciting investigations and they provide hope for many people with serious health problems, but they are also part of the mirage. None of them will provide perfect solutions to the disorders they are designed to address: a cochlear implant is not the same as a well-functioning ear, and stem cell research is still in such an early stage that it seems almost cruel to promise results to those who are sick today. As I put the final touches on this article, I found a report noting that disabling the protein p53, a tumor-suppressor protein, improves efficiency of stem-cell development (Krizhanovsky & Lowe, 2009). So another catch-22 seems to be looming on the horizon.
In the 1920s, the introduction of insulin treatment for diabetics seemed like a miracle cure, and it was, in the sense that diabetics who had little chance of surviving, could now live longer and better. But even today, insulin treatment is difficult and diabetics have more health problems than the average person. In addition, type 2 diabetes--the insulin-resistant kind--is on the rise so precipitously that it has been termed an "epidemic" in the United States, one tied to diet. Once again lifestyle seems the major factor responsible for a health problem (Taubes, 2009). Equally discouraging is the state of affairs with a genetic disease, cystic fibrosis. Another 2009 anniversary is the 20th for the discovery of the gene responsible, CFTR. This landmark promised to revolutionize treatment for this disease, but while CF patients are living longer, this is due primarily to medical treatments that aren't directly related to knowledge about the gene (Pearson, 2009).
It is also important to keep in mind that even when sophisticated treatments do become feasible, these "solutions" are also likely to be costly, both to bring to the stage where they are useful and for the treatment of each patient. These are definitely sophisticated approaches available only to those who can access sophisticated medical assistance. Though Dubos alluded to healthcare costs when he wrote, I don't think even someone as prescient as he could have predicted the healthcare situation today. After he wrote Mirage, Dubos became more and more interested in the environment's influence on health and also in global health issues. As is becoming more and more obvious, the two are related. There is evidence that the rise of HIV and Ebola virus infections as major health problems was due to the social and environmental changes that have swept Africa since the 1950s (Preston, 1994). Laurie Garrett's (1997) The Coming Plague: Newly Emerging Diseases in a World Out of Balance details case after case of the tie between environmental destruction and the spread of new infections. But you don't have to read a hefty tome to get that message, since local newspapers are full of stories about West Nile virus and Swine flu and ...
Biodiversity seems like a different issue from that of disease, but as a recent collection of reports indicates, there's increasing evidence that the two are closely linked (Chivian & Bernstein, 2008). Loss of habitat means that wild animals, and their pathogens, are more likely to be in contact with humans. If a parasite loses its host, it may solve its problem by finding a new host; and since humans have moved into its environment, it's not surprising that a number of the "coming plagues" were originally diseases of other species. Preserving biodiversity is often seen as a nicety the world cannot afford. The argument is made that land has to be converted to human use rather than kept in its natural state because humans need space to live and grow crops. But work on biodiversity and health makes it clear that saving species may be a self-serving enough aim to satisfy the most human-centric among us. It's not a high-minded argument in the tradition of Rene Dubos, but it's one that makes a great deal of sense today.
Chivian, E., & Bernstein, A. (Eds.). (2008). Sustaining life: How human health depends on biodiversity. New York: Oxford University Press.
Clausen, J. (2009). Man, machine and in between. Nature, 457, 1080-1081.
Couzin, J. (2009). Friendship as a health factor. Science, 323, 454-457.
Dubos, R. (1950). Louis Pasteur: Free lance of science. New York: Scribner's.
Dubos, R. (1952). The white plague: Tuberculosis, man, and society. Boston: Little, Brown.
Dubos, R. (1959). Mirage of health: Utopias, progress and biological change. New York: Harper and Row.
Dubos, R. (1968). So human an animal. New York: Scribner.
Garrett, L. (1997). The coming plague: New emerging diseases in a world out of balance. New York: Penguin.
Hendrick, R. (2002). Yes, syphilis originated in the new world and was brought to Europe by Christopher Columbus's crew. In N. Schlager (Ed.), Science in dispute (pp. 210-214). Farmington Hills, MI: Gale.
Kaeberlein, M., & Kennedy, B. (2009). A midlife longevity drug? Nature, 460, 331-332.
Krizhanovsky, V., & Lowe, S. (2009). The promises and perils of p53. Nature, '160, 1085-1086.
McNeill, W. (1976). Plagues and peoples. New York: Anchor.
Pearson, H. (2009). One gene, twenty years. Nature, 460, 165-169.
Preston, R. (1994). The hot zone. New York: Random House.
Roberts, L. (2009). Type 2 poliovirus back from the dead in Nigeria. Science, 325, 660-661.
Taubes, G. (2009). Prosperity's plague. Science, 325, 256-260.
Vogel, (3. (2008). Reprogramming cells. Science, 322, 1767.
Zinsser, H. (1935). Rats, lice and history. Boston: Little, Brown.
MAURA C. FLANNERY, DEPARTMENT EDITOR
MAURA C. FLANNERY is Professor of Biology and Director of the Center for Teaching and Learning at St. John's University, Jamaica, NY 11439; e-mail: email@example.com. She earned a B.S. in biology from Marymount Manhattan College; an M.S., also in biology, from Boston College; and a Ph.D. in science education from New York University. Her major interests are in communicating science to the nonscientist and in the relationship between biology and art.
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