Ticket To Ride

Should you find yourself in back country Uganda or Cambodia or Nicaragua, stop in at the local outdoor bazaar.  In any of these countries, the we’re-a-long-way-from-the-capital-amigo markets are surprisingly similar.  Spread out on rickety tables (upscale) or homemade mats you will find amazing varieties of local produce (covered with an amazing variety of local flies) mixed in with the detritus of the first world.

Alongside the melons and tubers and scrawny chickens you will find piles of worn truck tires, Denver Broncos T-shirts, generator spare parts, plastic  jewelry, etc., etc.  Depending on where you are, you might also find the latest CDs, Sony CD players on which to hear them and batteries with dubious life to power the players.  Again, depending on where you are, you might also find AK-47’s at reasonable prices, RPG’s (Rocket Propelled Grenades) at much higher prices, and ammunition of all calibers available by the box, belt, clip, or round.

But if you keep on browsing you will probably find something I find a good deal more frightening.  Spread out on a table or mat, with a smiling and sympathetic person behind them, you will find dozens of little pills.

No, these are not the hand rolled product of the local poppy grower or coca planter.  These pills are stamped with familiar names like Upjohn or Merck.  Flotsam of our huge medical sea, the latest medical technology lies strewn like multi-colored pebbles in the sun.

Why do I find this frightening?

It is not, as one might suppose, because these pills come with no proof that they really are what they pretend to be:  Prime, purified, full-strength products of Western science.  It is true that the fakes, frauds and diluted products are many, but that isn’t what scares me.  An appalling number of these are the real thing:  Original potency Western antibiotics.

They are sold, with no prescription beyond the helpful advice of your friendly salesman, by the individual pill.  And that is truly frightening.

Why?

It has been said that if you really want to pick up nasty, powerful, and potentially fatal bug in our modern world, a visit to your local hospital is your best bet.  There you will find the super-bugs, raised in a harsh, antibiotic rich environment to resist just about anything.

But the closed world of the hospital is not the only place we breed muscle-bound bugs.  Anyplace where incomplete drug regimens are followed can produce a super-bug.

Take MDR (Multiply Drug Resistant) tuberculosis as an example.  The difficulty there is that victims of this disease are supposed to keep taking their pills for months after all of the symptoms disappear.  If they do not, and if the bug population is merely suppressed, it can come roaring back.  Far worse is the fact that amongst the bug population, those most susceptible to the antibiotics will have been killed off.  Those that survive are likely to be at least somewhat drug resistant.  Spread that across thousands and tens of thousands of patients and you will have created an environment ideally suited to the forced evolution of super-bugs.

Many people, including me, have for some years looked to our own misuse of western medicine to produce the next plague.  We counted on our hospitals and our streets to produce a super-bug with vast ambitions.

Maybe, but maybe not.

It is certainly true that our casual use of antibiotics has produced some nasty bugs.  And it is true that our medicine cabinet and the drug development pipeline are getting pretty barren of new products to fight these new bugs.  But it is also true that most of these bugs are not really new.  They are just tougher versions of diseases that are already endemic and to which we are not a virgin population.

And we are a little smarter.

Nowadays, even your family MD is pretty savvy about antibiotics.  It wasn’t so long ago that a prescription was simply scribbled onto a pad and we were told, “This should take care of it.  If the problem persists, call me.”  Today you are more likely to get a stern warning to make sure that you continue taking your pills until they are gone, even if the symptoms go away.

You won’t hear any such lecture at that bazaar in the third world back country.  That smiling merchant will look at your rheumy eyes and sweating forehead, hear your sad story and point towards the kind of magic pills that will cure you.  A price will be quoted and, after some bargaining,  you will buy as many as you can afford.  You will take them home and, assuming they work, you will stop taking them as soon as you can and hoard the rest against a recurrence.

I cannot imagine a system better designed to make resistant bugs.

Once upon a time, the story of epidemics was all about travel.

Insofar as the history of man is concerned, the tropical and sub-tropical places of the world have shown an amazing capability to breed and grow diseases.  They also have a wondrous supply of boundlessly fertile disease vectors.  As humans bred and then pushed their boundaries into these areas, we inevitably became infected with new diseases.  Then we either adapted and settled there or retired, defeated (e.g. the tsetse fly areas of Africa were always considered too deadly for settlement, even by the hardiest locals).

When northern European traders reached these areas, they were simply fresh meat for the bugs.  Large areas of the world were considered too deadly for westerners (the famous White Man’s Grave countries).  You used local factors to handle your trade or you simply didn’t trade there.

As an unexpended and largely unperceived benefit, the indirectness of the trade with these areas and the slowness of travel had the effect of disinfecting both the trade goods and the traders.  That was the good news.  The bad new was that too many middlemen and too slow a transit had an effect too painful to be borne:  It ate into the profits!

So the traders, in their laudable effort to increase their margins, were constantly striving for more direct contacts with their markets and faster transits.  Inevitably, somewhere along this line a magic border was crossed and the accidental disinfection began to fail.

In October of 1347, Genoese trading ships sailed into Messina with cargoes from Turkey.  When inspected, they turned out to be floating horrors.  The crews were all dead or dying of a loathsome new disease with horrible symptoms.  The ships smelled like nothing on earth.

By accident, they had picked up another, unseen cargo:  Extremely healthy, hungry, and infected fleas.  It was the beginning of the Black Death.

Tracking it back, the Genoese had bought their goods from the Turks, who were the middlemen of the Near East.  The Turks, in turn, had bought their goods from those mighty travelers and traders, the Arabs.  The Arabs had long been trading with China, both over the disinfectingly long Silk Road and, lately, over the much faster sea route.  The Arabs had heard the Chinese were reporting a new and dreadful disease arising in their southern, sub-tropical provinces.

Fortunately, if one may use such a term, when the Black Death killed something over a third of the population of Europe, it incidentally broke down the system of trade that had made its spread possible.

That condition did not last, of course.  Population revived and with it, trade.  The Black Death was in a latent phase, but periodically other nasty diseases were picked up in the hot zones and carried home.  There were sporadic outbreaks in all of the major trading countries.

Since not trading was out of the question, we learned.  We learned the art of quarantine.  We came to see the connection between squalid conditions and the spread of disease.  Eventually, we even developed vaccines and other immunizations against most of the known tropical diseases.  There were occasional outbreaks, but they became local and easily controlled.

All of this knowledge and the exporting of western medicine soon caused another headache:  populations in the tropical regions burgeoned.  As the population pressure grew, people began to move into and cut down the tropical rain forests.  As they did so, they encountered new vectors and new diseases.  The best current theory of the origin of HIV/AIDS is that African settlers carried their habit of eating monkeys into their new settlements where new varieties of primates harbored a mutable simian HIV virus.  It happily hopped over to a new set of hosts.

This could turn into a very long essay on the epidemiology of diseases.  To summarize a bit brutally, let me say that most plagues in human history seem not to have arisen spontaneously in a stable population.  Rather, they have either arisen from a new population (like traders) encountering a region where the disease is already endemic (e.g. Yellow Fever, Malaria, etc.) or from a local population encountering a new vector for the first time.  And it is this second type of encounter that produces mutations in diseases, often to a more virulent form (e.g. HIV/AIDS).

Once a “new” disease has arisen, it becomes a matter of travel.  In any given population, diseases tend to peter out for lack of new victims.  Can this “new” disease find some method of getting to fresh victims before it naturally fades?  To put it another way, is there a boat to Messina waiting or not?

I think we should be concerned about the next plague, but I am no longer sure that we should keep our eyes only on our own streets or hospitals.  Rather I think we should be watchful of the third world.

Arguably, selling individual antibiotic pills produces an even better environment for forced mutation than our own.  This is enough of a cause for concern.  But let me add two others:

First, they are not playing around with MDR cases of whooping cough.  These are the areas that have traditionally produced the really hellish bugs.  They are potentially producing MDR versions of such charmers as Dengue, Malaria, Yellow Fever, Ebola and the like.  And some of those mutated strains could very easily produce pneumonic versions that would spread with unstoppable speed.

The second is very simply that it is still a matter of travel.  And today , medically speaking, no place on this earth is more than 48 hours from anywhere else.

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