“The Cholera Treatment Unit is working smoothly. It has seen about 150 patients since the epidemic began; five of those people have died. We step in chlorine shoe baths on our way into the Unit and have our hands washed with a high chlorine solution and soap. The doctor is Haitian, trained in Cuba. He talks about the speed with which cholera attacks, how it can quickly dehydrate you. In the recovery room, he introduces me to a patient who is ready to leave. ‘Two days ago she was admitted. She was crying, but she was so dehydrated she couldn’t make any tears. Now she’s ready to go home. We know how to beat this disease.’ ”
Diary entry by David Morley,
CEO, Save the Children
January 4, 2011, Gaston Magron
Health Services, Haiti
The cholera bacterium—Vibrio cholerae, named for its wiggling motion—occurs naturally where disaster and poverty collide. It crashes ashore on the waves of tsunamis, does the rounds of refugee camps and slums, and, as in the case in Haiti, thrives on the chaos following an earthquake.
Victims contract cholera by drinking water or eating food that is fouled by the excrement of other cholera sufferers. Once inside the body, cholera moves rapidly. Patients can lose so much liquid through diarrhea that they can die within two hours. Crippled by cramps, untreated patients waste away as their intestinal linings slough off as fishy-smelling stools that look like dirty dishwater. Dehydration and loss of salt result in falling blood pressure, a racing heart, the breaking of tiny blood vessels called capillaries, hollow eyes, and skin that’s blue and wrinkled. In their misery, victims curl up and die, often in the fetal position.
Cholera lives naturally in the environment today and probably originated in the Bay of Bengal, India. Although thought to have been around since ancient times, cholera gathered pandemic strength once people left farms for towns and cities. Poor sanitation and overcrowding in Indian cities, such as Calcutta, brought about the first major outbreak in 1817. The pandemic began when cholera bacteria, living in copepods (crustaceans) in the Bay of Bengal, came ashore in a storm and contaminated the local drinking water. Over the next few years, about fifteen million Indians died.
How does a bacterium go viral? Ships take in controlled amounts of water called ballast to maintain stability at sea. When ships sucked up ballast from the Bay of Bengal, the water they took on board was teeming with cholera bacteria from the untreated sewage of cholera patients. The ballast helped the ships sail on an even keel while traveling, but when water was removed from the ballast tanks and dumped in the bay in another port, cholera let loose a new storm of disease. There have been seven more global pandemics since then, as ships and travelers spread the disease across the Middle East, into Europe, and beyond.
Every year, between three and five million people fall sick with cholera, and over one hundred thousand die worldwide. Nearly four thousand people died following the earthquake in Haiti.
Cholera is a preventable disease. There is an effective cholera vaccine to stop the disease before it starts. For those who do become infected, IV fluids and antibiotics can quicken recovery. Oral rehydration drinks are a cheap and satisfactory cure, bringing eight out of ten patients back from the brink in just a few days.
In an emergency situation, all that’s needed is sterile water, sugar, and salt. But in a place ripped apart by war or natural disaster, even these simple ingredients can be hard to find, and many people can’t afford bottled rehydration drinks. Cholera is almost never reported in the developed world, but it is on the rise in the world’s poorest countries such as Haiti, Dominican Republic, Uganda, and Zimbabwe.
John Snow (1813–1858), the world’s first epidemiologist, was an English physician who was also curious about the spread of disease. He studied London’s 1854 outbreak of cholera, tracking down and recording deaths on a map.
At the time, unregulated private companies supplied citizens with water, and people bought their water from specific pumps. His detective work showed that most cases of cholera came from within a short distance of one shallow well that was dug near a cesspool. The Broad Street pump brought the water to the surface. He interviewed the families of victims living farther away and found that they also bought their water from the Broad Street pump—because they preferred its taste. Snow looked at water samples from the well under a microscope and saw “white, flocculent particles” that he connected with cholera.
Snow himself tended many cholera patients but never got sick. It made sense to him that cholera was carried into the body by drinking water and not by breathing bad air or miasma. He presented his findings and showed his map—known as The Ghost Map—to the London authorities. At his urging, the pump handle was removed and the outbreak stopped.
Preventative medicine at work! Or, so you’d think. Unfortunately, Snow’s conclusions were not taken seriously. As soon as the threat of cholera was gone, a new pump handle was installed. People didn’t want to believe that they were drinking water laced with neighborhood sewage. It took at least twenty more years for people to understand that miasmas don’t spread cholera. But Snow’s principal findings ring true today: safe drinking water and proper sewage treatment can eliminate this scourge forever.
You would never plunge your hands into a rotting carcass, pluck around with your bare fingers, roughly wipe your hands on a cloth, and then touch an open cut on a friend’s leg. Why not? For starters, you’d wear gloves and a mask and thoroughly wash between handling something putrid and touching a living person. So why did doctors in the early to mid-1800s dissect corpses in one room and deliver babies in the next without a bar of soap between them?
Back then, the medical profession was in its infancy, and patient care was primitive. Understanding and accepting the causes of most common diseases were still in the future. Despite limited tools and drugs, doctors pledged to do the best they could. Most trained as apprentices in hospitals and with individual physicians, learning the beliefs and techniques of their teachers and rarely challenging their elders. Occasionally, a young doctor who looked at the bigger picture would come along, identifying obvious problems and speaking out.
Ignaz Semmelweis was one of those doctors. Specializing in obstetrics in the 1840s, he worked with two maternity wards at a hospital in Vienna, Austria. In one ward, doctors and medical students attended pregnant women, in the other, midwives and their apprentices. The doctors moved back and forth between the morgue and the maternity ward, while the midwives stayed with the living patients. Childbed fever, a fever caused by an infection (sepsis) after childbirth, killed 29 percent of medical ward patients but only 3 percent of patients on the midwifery ward. Semmelweis did the math, but his colleagues refused to believe that they could make their patients ill.
In 1847, one of the senior doctors, Professor Jakob Kolletschka, cut his finger while performing an autopsy and developed an infection identical to that of the women on the maternity ward. When Kolletschka died, Semmelweis connected the dots and insisted on hand-washing with chlorinated water before every delivery. Childbed fever almost disappeared overnight. You’d think that Semmelweis would have been hailed as a hero for his discovery, but the opposite actually occurred.
Frustrated by the stupidity of his colleagues, he left Vienna and returned to his native Budapest, Hungary. Again, Semmelweis introduced hand-washing and the number of deaths from childbed fever fell to near zero. His Hungarian colleagues challenged his reasoning, and Semmelweis finally went mad. He was admitted to hospital and died a few weeks later of sepsis—the same infection he had worked to eliminate.
Semmelweis may have been a forward thinker, but Florence Nightingale, the founder of modern nursing, was way ahead of her time.
Born into a wealthy English family in 1820, Nightingale’s future should have been predictable: a genteel education in music, embroidery, and perhaps French; a spoiled youth with dances and holidays by the sea; suitable marriage, lots of servants, children, and a life of leisure. Her family did not approve, but she veered off this path and blazed her own. She studied mathematics, traveled to Europe, and volunteered at hospitals and orphanages—all the while keeping notes and records of her experiences.
Nightingale believed in the miasma theory of infection—foul air was responsible for disease—but she was also a stickler for cleanliness. As superintendent of London’s Institution for the Care of Sick Gentlewomen in Distressed Circumstances in 1853, Nightingale observed that patients and their beds were dirty, that water was scarce, and that nutrition was poor.
She demanded things change. Starting with the basics, she ordered healthy meals, proper plumbing, clean laundry, clean bandages, and ventilation. She didn’t know that her high standards of hygiene would reduce infection and speed healing.
Florence Nightingale earned the name Lady of the Lamp when she applied her methods of cleanliness to field hospitals during the Crimean War of 1854. She worked tirelessly by day, but she also checked on wounded soldiers by lamplight at night, establishing around-the-clock nursing care.
For Nightingale, neglect was not an option. Before her regime of mops, soap, and clean sheets, almost half of the wounded died. After, the death rate fell to 2 percent. Like Semmelweis, she met resistance within the medical profession as well as from the military, but when the war was over, her work earned respect and honor back home in England.
Nightingale’s long-lasting contribution was the establishment of the world’s first professional nursing school in London’s St. Thomas’ Hospital in 1860. To this day, graduating nurses take the Nightingale Pledge and celebrate International Nurses Day every year on her birthday, May 12.
Elizabeth knew something was very wrong before she even opened the door. Dad’s car was in the driveway at four o’clock on a Tuesday. Her fears deepened when she saw her parents sitting in the living room, looking sad. Had someone died?
Elizabeth’s mother explained that Dad was going to a sanatorium, a hospital exclusively for patients with tuberculosis, or TB. He would be isolated for about a year with other TB patients, breathe fresh air, eat nutritious food, and receive vigorous and extensive antibiotic therapy. Incredibly, the year was 1963. Dad wasn’t a soldier going off to war or a convicted criminal confined to prison, but he was going away just the same.
Dad caught TB from a coworker who’d recently moved from Eastern Europe. The man had been infected with TB as a child, and the disease had been dormant for years. Recently, it had quietly reactivated, making him infectious. Before he’d known he was sick, he’d passed the disease on to Elizabeth’s dad.
Children younger than twelve couldn’t visit, but every Sunday for the next sixteen months, Elizabeth sat in the car in the parking lot of the sanatorium and waited for Dad’s wave from the window. After he was discharged, doctors said he was cured, but he would always test TB-positive and a chest X-ray would show the scars on his healed lungs. Despite making a full recovery, doctors knew that his TB could reactivate in the future.
Fifty years ago, tuberculosis was uncommon in North America and the developed world. An accurate skin test that identified those patients with the disease—even those without symptoms—and antibiotics to fight the infection had nearly wiped out this dreaded illness. What was it like before antibiotics? That’s a very different story!
Tuberculosis, TB, consumption, white plague, wasting disease—whatever you call it, the course is predictable. Patients who develop active TB and are not treated suffer a slow, downhill course of health and usually die. In one form of the illness, patients’ symptoms progress very quickly, and this is called galloping consumption.
Pulmonary tuberculosis, the most common form of tuberculosis, settles in the lungs and creeps up on the victim like a mild cold. But once a cough begins, the tuberculosis bacterium digs into the lung tissue. When the patient starts hacking up blood followed by gobs of mucus mixed with particles of tissue, TB has obviously taken hold.
Fever, chest pains, night sweats, and chills further drain energy from the body. Eating becomes difficult and body weight drops drastically. Nearing death, the patient looks like a skeleton on the outside, with lungs resembling foul cottage cheese on the inside.
People domesticated cattle and began drinking unpasteurized milk (now a known way to get TB) between six and eight thousand years ago. And ancient human remains, including the mummy of King Tut, show evidence of tuberculosis. Today, TB still causes up to three million deaths a year worldwide. TB has been labeled the number one cause of death of all time.
Before modern treatment, people tried a variety of desperate so-called cures: eating lobster, drinking donkey’s milk, taking a long sea voyage, breathing the smoke from burning cow plops, and eating mice boiled in oil. Surgeons also tried their hand at finding a cure, but these radical procedures—including the deliberate collapsing of the lung to allow it to rest, and the removal of ribs—proved useless.
Great medical minds puzzled over the mysteries of tuberculosis, with observations and theories adding to our understanding over time. Hippocrates, the ancient Greek physician, called the disease phthisis, meaning “to waste.” He came close to understanding the source of infection by connecting phthisis with air.
Aristotle, the Greek genius who lived from 384 to 322 BC, correctly suggested that phthisis could be spread from one person to another.
It wasn’t until 1650 AD in Germany that anatomist Franciscus Sylvius discovered that the lungs of those dying of TB were full of little nodules he called tubercles.
In 1865, the French physician Jean Antoine Villemin scientifically proved that TB was infectious and not hereditary. During his laboratory experiments, he passed the illness from both people and cattle onto rabbits. Despite the fact that about one in four of all people died of TB, most of Villemin’s fellow scientists ignored his results and refused to isolate TB patients from the general public. In Poland, however, at about this time, the first tuberculosis sanatorium hospital opened.
While giving a lecture on March 24, 1882, Robert Koch, a German bacteriologist, rocked the scientific community when he revealed he’d isolated the bacterium responsible for tuberculosis. From the podium, he railed, “If the importance of a disease for mankind is measured by the number of fatalities it causes, then tuberculosis must be considered much more important than those most feared infectious diseases, plague, cholera, and the like.”
Then he invited the astonished audience to look at his specimen slides under the microscope. He didn’t want his colleagues to dismiss his words, so he brought the slides as physical proof they could see with their own eyes.
Koch tried to develop a vaccine for tuberculosis, but he didn’t succeed. When he cultured and sterilized tubercle bacterium and injected it into a patient, it did not prevent TB. However, his work did form the basis for a valuable diagnostic tool—the TB skin test. Still used today, this test identifies if a patient has been exposed to TB. One in four people in the world today produce a positive TB skin test.
Koch’s work inspired city governments to improve sanitation. New York led the way by banning public spitting in 1896, hoping to reduce the spread of tuberculosis. The bacterium can also survive in the moist droplets expelled through sneezing, coughing, singing, laughing, and talking.
Koch was awarded the Nobel Prize in 1905 for his contribution to the tuberculosis puzzle, but a cure was still years away. It took almost four decades to piece it all together.
In 1944, Americans Selman Waksman and his graduate student Albert Schatz discovered an antibiotic—streptomycin—that kills the tubercle bacterium.
But tuberculosis, like a rat, is a super-survivor. In a few short years, the bacterium mutated or changed, and streptomycin could no longer do the job alone. Soon, a cocktail of several antibiotics was needed—taken for six months or longer. Still, TB was in retreat, the number of cases fell, and the once-full sanatoriums closed for lack of patients.
The modern medicine community thought they’d conquered the enemy, and Western governments cancelled TB control programs. Then, in the late 1980s, tuberculosis came back, attacking vulnerable members of society: those who were HIV-positive, intravenous drug users, and people living in confined areas such as prisons, nursing homes, crowded urban neighborhoods, and in large, extended family groups on First Nations reserves.
In Nunavut, the largest territory in Canada, the infection rate is sixty-two times higher than in southern Canada. Some municipalities offer incentives such as a free hamburger and fries to patients who stick with the long course of antibiotics. In Canada, governments publish an educational comic book that teaches readers that TB is curable.
Families such as Elizabeth’s remember the pain of tuberculosis—physical discomfort combined with separation from loved ones. Back when TB loomed over society and everyone knew someone with the disease, folklore connected TB with a creative mind. In the nineteenth and twentieth centuries, many celebrities died of TB—such as musician Frédéric Chopin, poet John Keats, former First Lady of the United States Eleanor Roosevelt, and screen actress Vivien Leigh. The ghastly symptoms of tuberculosis were made romantic in books, operas, and movies. Heroines were thin, rosy cheeked, and glassy-eyed. “Coughing blood into a silk handkerchief, she took her last breath, blowing a kiss to her beloved.”
Madeleine lay pale and listless on bedsheets soaked from her feverish sweat. Wiping off the mustard plaster poultice with a warm towel, Maman shook her head as Madeleine coughed again. She was definitely worse. Finally, her worried parents agreed they’d better send for the doctor.
Claude, her elder brother, ran to the stable, saddled his pony, and sped off down the dirt track into the last light of day. When the doctor arrived the next morning with his horse and buggy, he came in through the tradesmen’s entrance, hanging his coat in the back kitchen.
Madeleine’s breathing was shallow as he opened his doctor’s bag and laid out its contents on the bedspread: two bottles of tonic, one elixir for cough, a packet of dried herbs, tweezers, a leather pouch protecting a scalpel, and a vial of squirming leeches. Lastly, he pulled out a shiny new stethoscope—an instrument the family had never seen before.
In the mid-1800s, people throughout the world dreaded sickness. About half of all European babies died before they turned two. If a male survived until his fiftieth birthday, he was lucky. Females usually died younger, often in childbirth.
When patients such as Madeleine spiked a fever, they were sponged with cool water and given herbal tea to drink. Infected tonsils were removed with a primitive surgical instrument called a tonsil guillotine, and the surgeon didn’t wash his hands or sterilize his tools.
Bloodletting was a cure-all for the sick and a preventative measure for the healthy. With limited knowledge and resources, the medical profession knew so little—yet they had no idea how little they knew!
Today, that has all changed thanks in large part to the groundwork of Louis Pasteur.
On December 27, 1822, Louis Pasteur was born into a family of tanners. Tanning is a process that uses chemicals to transform animal skins (which naturally rot and stink) into leather that endures for years as saddles, chairs, boots, and so on. His hardworking family schooled Pasteur in the importance of following the steps of a recipe, and this proved to be an excellent set of skills for a future chemist.
Later in life, as a professor in chemistry, Pasteur compared his laboratory experiments to detective work. Beginning with a mystery, he gradually peeled away layers, eventually solving a problem. His persnickety scientific methods raised the bar for other scientists—and brought him admirers as well as rivals. He believed that “chance favors only the prepared mind”—lucky discoveries are made by alert and ready thinkers. As head of the department of chemistry in 1854 at University of Strasbourg, in France, Pasteur figured out the process of fermentation. Fermentation is a chemical reaction that turns decomposing grain or fruit into alcohol. His discovery made it possible for beer and wine to be produced on a large scale.
Pasteur also helped a manufacturer determine why his beet juice vinegar went sour. On this case, he looked at the vinegar under a microscope and observed tiny microbes. He heated the beet juice and killed the microbes, making the juice sterile. This process, later named pasteurization, revolutionized food safety.
What does pasteurization have to do with health or pandemics? The pasteurization of milk greatly reduced the incidence of tuberculosis and salmonella poisoning from eating rotten milk or cheese.
Pasteur refused to believe in spontaneous generation—a theory that had been accepted since the Middle Ages and was supported by Bible stories—which describes the creation of living things from non-living matter.
A popular proof dating back to the mid-1600s supporting spontaneous generation was the sudden appearance of mice in a pail of grain where soiled, sweaty underwear had been left for twenty-one days. A keen observer would soon discover that mice came to feed on the grain, and the underwear provided comfy bedding.
An experiment conducted by an Englishman named John Needham in 1745 provided another example to support spontaneous generation. He boiled chicken broth, killing all microbes. Then he allowed the broth to sit, uncovered, at room temperature. When it became cloudy, he reasoned new life had “sprung forth” from the broth—evidence of spontaneous generation.
Pasteur disproved Needham’s claim by repeating the experiment, but this time, Pasteur stored the broth in a swan-neck flask, preventing microbes from reaching the sterile broth.
As an alternative to spontaneous generation, Pasteur proposed his “germ theory.” He insisted that microbes, or germs, were the scientific cause for the spark that triggers disease. He set about isolating the microbes responsible for deathly diseases such as anthrax and rabies, with the hope of preventing the spread of these infections.
Edward Jenner, from England, created the first vaccine in 1774, but he never knew why it worked. Pasteur solved the riddle of vaccination and tried applying the idea to other microbes.
Pasteur’s German rival, Robert Koch, isolated the anthrax bacterium that lives in soil and kills livestock. Pasteur used Koch’s bacterium to develop a vaccine and he tested it on cattle, sheep, and a goat. He conducted his experiment in public so that everyone could see his methods, making it difficult for naysayers to criticize the results. All the animals he vaccinated and then exposed to an anthrax culture survived. Those exposed to just the disease died. The success of this experiment gave Pasteur more evidence for his germ theory.
Rabies was a harder case to crack. Until this point in time, rabies had always been fatal. Even though Pasteur knew it was a virus, he could not see it with his ordinary microscope. Through experiments on rabbits and then dogs, Pasteur learned that rabies has a long incubation period. It eventually became clear that rabies could not be prevented, but Pasteur hoped a vaccine might be a cure.
He devised a series of fourteen vaccines that increased in strength, and gave infected animals one injection per day for two weeks. The dogs that he’d vaccinated lived; the others died of rabies.
Joseph Meister, a nine-year-old boy who’d been bitten fifteen times by a rabid dog two days earlier, was Pasteur’s first human test subject. It was July 1885. When Joseph’s doctor couldn’t help him, the doctor suggested his family try Pasteur, even though Pasteur lacked medical qualifications.
The boy received the same fourteen-day regime as Pasteur’s dogs—and lived. Today, domestic pets are vaccinated to prevent rabies, and people who are bitten still receive a series of painful needles to prevent the disease from developing.
Louis Pasteur’s legacy continues on in the Institut Pasteur in Paris. Founded in 1887 as a laboratory where Pasteur and his associates worked on infectious diseases and vaccines, it remains an international hub of medical and scientific research.