BIOLOGY TODAY TheMirageofHealth

MAURA C. FLANNERY, DEPARTMENT EDITOR

I am writing this column in late August, so it's difficult to predict to , that the reign of these drugs was likely to be short what the HI N I flu situation will be by like the time it is published lived and could only be extended by human ingenuity working towards the end of the year. Since there is already a pandemic, to keep one step ahead of the microbes. Dubos was born and the spread of the virus will likely have picked up more steam by educated in at the beginning of the 20th century, when Downloaded from http://online.ucpress.edu/abt/article-pdf/71/9/558/55307/20565381.pdf by guest on 27 September 2021 that time, but how much steam it is difficult to forecast So I'm French was still very much under the sway of Louis not even going to try. Instead, Iwill make a prognostication that Pasteur's intellectual heritage. He came to the and is a safer bet: there will continue to be health issues of some kind spent most of his career as a researcher at what is now Rockefeller at the end of this year, at the end of this century, and on to the University in . There he discovered gramicidin, the first end of this millennium. I am using as my crystal ball a book by clinically tested . While it didn't prove to be an effective Rene Dubos (1901-1982) called Mirage of Health (1959). It seems drug, Dubos's research did yield useful information on antibi appropriate to examine this book on the fiftieth anniversary of its otic dynamics both in culture and in living organisms. When publication, because it is at least as relevant today as itwas at the penicillin was discovered and being developed as a drug, he was time it came out. Also, since this issue of ABT is devoted to health involved in the early work done in the United States. He also did and medicine, this work is a great reminder of the limits of the research on tuberculosis and pneumonia. latter to ensure the former. It was Dubos's studies on how bacteria became resistant to The book's main argument is that, as the title suggests, the effects of antibiotics that led him to consider the theme of the quest for perfect health is an unending one, just as walking health as amirage. By this time, in addition to his journal articles, towards amirage is a fruitless task. Dubos contends that the idea Dubos had already published two books for the general reader: a that better days are coming, that ifwe get rid of the latest scourge biography of Pasteur (1950) and a book on tuberculosis (1952). to health, life will be wonderful and we will to a ripe old age in Inmidlife, he had discovered his gift for communication and went good health, just isn't going to happen. In other words, finding on to publish over a dozen more books, including So Human the "cure" for cancer or HIV infections or . . . isn't going tomake an Animal (1968) for which he received the Pulitzer Prize. The lifewonderful. He cites as support for his view the fact that find subtitle for The Mirage of Health is Utopias, Progress and Biological ing a cure for tuberculosis (TB), the scourge of the 19th century, Change, and Dubos addresses the question of health from each of did not lead to a health utopia. In fact, thanks to life style changes these three perspectives. He came from a European tradition of rather than medical advances, the incidence of TB had already deep and broad learning; he was well-versed in history so he situ decreased significantly even before an antibiotic treatment for this ates his argument in terms of past efforts to improve health. He bacterial infection became available in the 1950s. describes why any hope that persistent efforts will lead to a future without disease are hardly of recent origin, though attempts to I have been reminded of Dubos's book frequently over the achieve this goal may have been of very different kinds in the past. years since I first read it in the 1970s. Most particularly, it came Ponce de Leon's search for the fountain of youth was one manifes tomind in the 1980s when HIV and then Ebola virus entered our tation of this predilection because youth and health are obviously consciousness. For those who don't remember these times, both related to each other as are old age and illness. Others saw such infections came as rather a shock to the American public who had utopias as existing in unspoiled parts of the such as the become accustomed to the idea that infectious disease was no lon world, islands of the South Pacific, where civilization had yet to intrude. ger fatal. To put it very simply, bacterial infections could be treated The link between civilized life and problems was emphasized by with antibiotics and viral diseases prevented with vaccines. Then Rousseau who saw a move back to nature as the cure no only for AIDS arrived, an infectious, incurable and in those early years, physical but social ills. 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 Balance and the Environment bacterial pneumonia was dangerously common and a bad cut Dubos also further back in to the time ancient could lead to an uncontrollable infection. goes history of the Greeks and of course, to Hippocrates who considered health a Microbiology 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 How could Dubos have been so prescient when most Americans humors or fluids in the body: black bile, yellow bile, phlegm, and were shocked by this onslaught and the others to follow? First blood. This idea of health as balance continued to be an important of all, he was a microbiologist. He was already aware, more than theme in approaches to keeping people well and is still significant most people of the time, that bacteria were developing resistance today. We are warned not to: not eat too much or too little, not

a THEAMERICAN BIOLOGY TEACHER VOLUME71,NO. 9,NOVEMBER/DECEMBER 2009 to over exercise but to exercise "enough," not to loaf or work too social and political turmoil. Such upheavals include not only wars hard, etc. Hippocrates saw the environment in which a person and revolutions, but also floods, earthquakes, and other natural lived as important to balance, so there needed to be equilibrium disasters. in interactions with nature as well as within the human being. However, Dubos looks at the other side of the coin as well Others saw illness in more specific terms, with different illnesses and examines the social and political environments which lead having different causes and resulting in different problems within to health improvements. He argues that tuberculosis, bacterial the body, what came to be called the "specific etiology" view pneumonia, and cholera had become much less lethal in the 19th of disease. This is obviously the dominant opinion in medicine century, well before the discovery of the specific etiologies of today, and Dubos traces its development and its consequences, these infections. Better sanitation and improved living conditions focusing on medical approaches to, not surprisingly, infectious were responsible for this improvement. When I first read this, it disease, especially in the 19th century. This was when microbiol really impressed me, and I have emphasized this when presenting ogy was beginning as a science, when Koch, Pasteur, and others infectious disease topic to students. Pasteur and his successors were identifying specific organisms as the cause of specific kinds did a very good job of indoctrinating the public with the idea that of illnesses. But this cause-and-effect relationship was not always if the infectious agent is removed so is the disease. But itmakes clear-cut and many in the field questioned it. They argued that a big difference when that removal takes place-before or after an diseases such as tuberculosis and cholera were not the result of individual is infected. Drugs may lessen the effects of infections, invisible organisms but rather of the conditions of life. but it's better not to get them.

Itwas well-known that those who lived in poverty were more Downloaded from http://online.ucpress.edu/abt/article-pdf/71/9/558/55307/20565381.pdf by guest on 27 September 2021 likely to suffer and die from these diseases. Elie Metchnikoff, Life Style a leading microbiologist of his day who was appointed to the Dubos was looking at the other side of the coin, preventing con Pasteur Institute by Pasteur himself, was of the view that environ tact with infectious organisms, when he argued that environmen ment was the real cause of disease. To prove this in the case of tal change was such a powerful force for better health. It was in cholera, he drank a solution containing a large number of these the 19th century that sewage systems were installed in European bacteria, yet he didn't contract the disease. Of course, Pasteur's and American cities, thus separating waste water from drinking own work countered this view. He had found that cultures of water and keeping people from a significant infection source. chicken cholera could be used to infect other chickens, and the Today, childhood diarrhea is still one of the major causes of death same was true for anthrax and rabies. in many parts of the world because such basic sanitation is still This apparently fundamental difference in results is a good lacking over large areas. But itwas more than just sewers that led example of why research is difficult to do and why significant to improved health in the 19th century; itwas also a general rise questions can remain unresolved for long periods. As we know in the standard of living. People had more money to spend on today, specific infectious organisms cause specific symptoms, but food, so they ate better and thus were in better shape physically to there are usually several environmental factors involved in the fight infection. They were also better able to heat their homes. In spread of disease. One of the reasons HiN 1 flu spread so quickly the United States, we take central heating for granted today, but is because of air travel. As the epidemic took off in Mexico, the this was a luxury formany well into the 20th century. We think of first cases in the United States were not in a border state like heat in terms of comfort, yet it also makes us a lot healthier. First Texas, but in New York, at a high school about half a mile from of all, energy that would have to go to staying warm can be used where Iwork. Why? Because several students in the school had to strengthen the immune system, and also, warm air is easier on spent their spring break in Cancun, Mexico. The spread of HIV the lungs, making for healthier respiratory systems. It is no coin was slower and more stealthy, but again, an infection that arose in cidence that "colds" have that name. Dubos also credits public Africa soon had toeholds in the United States and Haiti-and then health efforts and social reformers for creating living and working beyond-because of the ease of international travel. conditions that put less stress on the body and led to a healthier population. These factors made tuberculosis less dangerous and History dreaded while the only "cure" remained rest and living in an envi ronment with clean air. In early centuries, travelwas slower, but still a factor in the spread of infection. There is good evidence, though it doesn't convince Yes, people still died of tuberculosis into the 1950s, when everyone, that syphilis originated in the New World and didn't antibiotics were discovered to clear the body of the bacillus that reach Europe until the Age of Discovery (Hendrick, 2002). Years caused this disease. However, people still die of TB today because ago, the historian William McNeill (1976) wrote a comprehensive there are strains resistant to standard treatments. As Dubos sug work called Plagues and Peoples in which he argued that infectious gested, the idea of perfect health remains amirage. Yes, theWorld disease had a great influence on the course of history. The decima Health Organization was able to rid the earth of smallpox in the tion of Napoleon's army in Russia is just one example, and others 1970s, however, that is still a singular triumph. The aim has been stretch much farther back in time. McNeill contends that diseases to do the same for polio, but just recently, I saw an article on a like bubonic plague came into Europe with invading armies from major setback to this effort (Roberts, 2009). While type 1 and 3 the east in medieval times. Wars also lead to the kinds of condi poliovirus remain at large, type 2 had been wiped out throughout tions-poor sanitation, large numbers of people living in close the world by 1999. It's now back causing infections in Africa. quarters, famine-that create the perfect environment for the This year 124 cases of type 2 paralysis had been reported by spread of infection. Dubos makes the same case in his book, July-four times more than last year. Its source is the weakened though in lesserdetail, and he citesHans Zinsser'sRats, Lice and form of the virus found in the live vaccine used to eradicate History(1935) where Zinsser,another microbiologist, charts the the disease.Here is one of those catch-22 situations in public history of typhus, very convincinglypresenting evidence that health, and one of the reasonswhy ridding theworld of polio is this infectionis transmittedby liceon rats.Yet typhus looks like still a tantalizingmirage. In otherwords, every effort to improve an environmentaldisease because it is so often found in areasof health has its unwanted,and often unexpected consequences:a

THE AMERICAN BIOLOGY TEACHER BIOLOGY TODAY a I *.. S Downloaded from http://online.ucpress.edu/abt/article-pdf/71/9/558/55307/20565381.pdf by guest on 27 September 2021

live-virus vaccine is easy to administer, but can lead to reversion ologist who studies social isolation's health consequences. In the of the virus to a virulent form; antibiotics can trigger allergies and 1980s, she found that those who tended to be less social also were resistance; mammograms mean exposure to cancer-causing radia more likely to die over the next seven years. Since social isolation tion; surgical procedures, no matter how simple, can go wrong. is often related to risky behaviors like drug or alcohol abuse, this I'm stating the obvious here, but especially as the nation tries to was not surprising, but even when such factors were ruled out, deal politically with its healthcare problems, Dubos's viewpoint the risk was still over twice as high for the less social. This result bears investigation. has been replicated many times, but when Berkman tried various interventions to encourage social interactions among patients, Social Networks the outcomes weren't always positive, perhaps because by the time these individuals were identified, their health problems were I don't think good healthcare is the be-all and end-all for a good irreversible. quality of life. I have some experience in facing realities, and I myself have had to choose between the best health care and the Berkman's work is reminiscent of those studies showing most user-friendly and I chose the latter. Sometimes health has that having a pet increases mental and physical well-being. (Fly little to do with healthcare. I just read an article about research is lying-asleep of course-near my desk right now as a reminder showing that friendship is a major factor in health and that not of this, and I had a good report at my annual check up this week. all friendships have a positive effect (Couzin, 2009). Research What more research has to be done on this connection!) That on social networks indicates that people who smoke tend to be something as simple as a phone call-or lick on the face-could friendly with other smokers (all you have to do is stand outside improve health is indicative of Dubos's main argument, that an office building to know this is true). Smokers aren't just being health involves more than medicine, so conversely, medicine can't sociable, they are also encouraging each other's unhealthy behav be looked upon as the savior that will bring perfect health. Let's iors. The overweight tend to find each other as well, perhaps face it, the human body isn't perfect and it gets less perfect with because they feel less guilty about having dessert at lunch when age-even dog owners die, eventually. But compared to some of their friend is also ready for pie. the trends in medical research today, these social interventions seem simple and powerful. 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 Consequences of Medical Science the University of California, San Diego took advantage of one Yet despite all this evidence, medical science is still looked to as question recorded on the charts of the 15,000 participants: Name the source of better health in the future. To mention a few areas a close friend who can find you in case we can't. They tracked of research receiving attention: there's work on rapamycin, a drug down information on the long-term health of the participants and that significantly extends the life of mice, and some see as a pos their contacts, finding that "every facet of health examined so far sible anti-aging drug for humans (Kaeberlein & Kennedy, 2009); appears to 'spread' from person to person" (p. 454). These facets brain-implantable devices for the deaf and the blind (Clausen, include smoking, obesity, happiness, unhappiness, and alcohol 2009); reprogramming of cells as a way to create stem cells to ism. The researchers are criticized both for just stating the obvi treat particular disorders from Parkinson's disease to paralysis ous and also for overstating the importance of their results. But (Vogel, 2008). These are all exciting investigations and they findings are at the very least interesting, and bring up still another provide hope for many people with serious health problems, factor in healthiness and illness. but they are also part of the mirage. None of them will provide There is also other work suggesting that creating positive perfect solutions to the disorders they are designed to address: social networks can improve health. Lisa Berkman is an epidemi a cochlear implant is not the same as a well-functioning ear, and

THE AMERICAN BIOLOGY TEACHER VOLUME 71, NO. 9, NOVEMBER/DECEMBER 2009 a stem cell research is still in such an early stage that it seems almost cruel to prom- - ise results to thosewho are sick today.As I W Er I put the final touches on this article, I | found a ; I 1 U*?,un< report noting that disabling the protein p53, a tumor-suppressor protein, improvesefficiency of stem-celldevelop- - B-1CORPORATION HASOVER ment (Krizhanovsky & Lowe, 2009). So t _ another catch-22 seems to be looming on 3 Lt3 U n the horizon.thehorizon. lii U " - -PECIMENS INSTOCK C^ORPORATION In the 1920s, the introduction of insulin treatment for diabetics seemed like amiracle cure, and itwas, in the sense that diabetics who had little chance of surviv ing, could now live longerand better.But ONEYEAR GUARANTEE ON PRESERVED SPECIMENS even today, insulin treatment is difficult and diabetics have more health problems

than the average person. In addition, type loses its host, itmay solve its problem by finding a new host; and Downloaded from http://online.ucpress.edu/abt/article-pdf/71/9/558/55307/20565381.pdf by guest on 27 September 2021 2 diabetes-the insulin-resistant kind-is on the rise so precipitous since humans have moved into its environment, it's not surprising ly that it has been termed an "epidemic" in the United States, one that a number of the "coming plagues" were originally diseases tied to diet. Once again lifestyle seems themajor factor responsible of other species. Preserving biodiversity is often seen as a nicety for a health problem (Taubes, 2009). Equally discouraging is the the world cannot afford. The argument is made that land has to state of affairs with a genetic disease, cystic fibrosis. Another 2009 be converted to human use rather than kept in its natural state anniversary is the 20th for the discovery of the gene responsible, because humans need space to live and grow crops. But work on CFTR. This landmark promised to revolutionize treatment for this biodiversity and health makes it clear that saving species may be a disease, but while CF patients are living longer, this is due primar self-serving enough aim to satisfy the most human-centric among ily tomedical treatments that aren't directly related to knowledge us. It's not a high-minded argument in the tradition of Rene about the gene (Pearson, 2009). Dubos, but it's one that makes a great deal of sense today., It is also important to keep in mind that even when sophis ticated treatments do become feasible, these "solutions" are References also likely to be costly, both to bring to the stage where they are useful and for the treatment of each patient. These are defi Chivian, E., & Bernstein, A. (Eds.). (2008). Sustaining life: How human health on New York: nitely sophisticated approaches available only to those who can depends biodiversity. Oxford University Press. access sophisticated medical assistance. Though Dubos alluded Clausen, J. (2009). Man, machine and in between. Nature, 157,1080-1081. to healthcare costs when he wrote, I don't think even someone Couzin, J. (2009). Friendship as a health factor. Science, 323,454-457. as prescient as he could have predicted the healthcare situation Dubos, R. (1950). Louis Pasteur: Free lance of science. New York: Scribner's. today. After he wrote Mirage, Dubos became more and more R. The white interested in the environment's influence on health and also in Dubos, (1952). plague: Tuberculosis, man, and society. Boston: Little, Brown. global health issues. As is becoming more and more obvious, the two are related. There is evidence that the rise of HIV and Ebola Dubos, R. (1959). Mirage of health: Utopias, progress and biological change. New virus infections as major health problems was due to the social York: Harper and Row. and environmental changes that have swept Africa since the 1950s Dubos, R. (1968). So human an animal. New York: Scribner. (Preston, 1994). Laurie Garrett's (1997) The Coming Plague: Newly Garrett, L. (1997). The coming plague: New emerging diseases in a world out of bal Emerging Diseases in a World Out of Balance details case after case ance. New York: Penguin. of the tie between environmental destruction and the spread of Hendrick, R. (2002). Yes, syphilis originated in the new world and was brought new infections. But you don't have to read a hefty tome to get that to Europe by Christopher Columbus's crew. In N. Schlager (Ed.), Science in message, since local newspapers are full of stories about West Nile dispute (pp. 210-214). Farmington Hills, Ml: Gale. virus and Swine flu and ... Kaeberlein, M., & Kennedy, B. (2009). A midlife longevity drug? Nature, 160, 331 Biodiversity seems like a different issue from that of disease, 332.

but as a recent collection of reports indicates, there's increasing Krizhanovsky, V, & Lowe, S. (2009). The promises and perils of p53. Nature, 160, evidence that the two are closely linked (Chivian & Bernstein, 1085-1086. 2008). Loss of habitat means that wild animals, and their patho McNeill, W. (1976). Plagues and peoples. New York: Anchor. gens, are more likely to be in contact with humans. If a parasite Pearson, H. (2009). One gene, twenty years. Nature, 160,165-169.

Preston, R. (1994). The hot zone. New York: Random House.

L. MAU RA C. FLANN ERY is Professor of Biology and Director of the Center for Teaching Roberts, (2009). Type 2 poliovirus back from the dead in Nigeria. Science, 325, 660-661. and Learning at St. John's University, Jamaica, NY 11439; e-mail: flannerm@stjohns. edu. She earned a B.S. in biology from Marymount Manhattan College; an M.S., Taubes, G. (2009). Prosperity's plague. Science, 325, 256-260. also in biology, from Boston College; and a Ph.D. in science education from New Vogel, G. (2008). Reprogramming cells. Science, 322,1767. York University. Her major interests are in communicating science to the nonsci entist and in the relationship between biology and art. Zinsser, H. (1935). Rats, lice and history. Boston: Little, Brown.

THE AMERICAN BIOLOGY TEACHER BIOLOGY TODAY a