Plague Time: How Stealth Infections Cause Cancers, Heart Disease and Other Deadly Ailmentsby Paul W. Ewald, Paul Ewald
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According to conventional wisdom, our genes and lifestyles are the most important causes of cancer, heart disease, and other killer ailments today. Conventional wisdom is wrong. In this bold, visionary book, biologist Paul W. Ewald argues that these serious illnesses are caused by a virtual plague of chronic infections. Acute infections give the sufferer symptoms almost immediately; the flu, cholera, even Ebola are all well-known and easy-to-identify examples of acute illnesses. Chronic infections, however, are stealthy predators that may not produce any symptoms for decades, and so remain almost undetectable, but eventually they ruin the sufferer's life. The netherworld of stealth infections is now opening before us.
In Plague Time, Ewald puts forth an astonishing and profound argument that challenges our modern beliefs about disease: it is germs -- not genes -- that mold our lives and cause our deaths. Building on the recently recognized infectious origins of ulcers, miscarriages, and cancers, he draws together a startling collection of discoveries that now implicate infection in the most destructive chronic diseases of our time, such as heart disease, Alzheimer's, and schizophrenia.
Acclaimed for years as one of the most important thinkers alive today on the genesis of disease, Ewald now explodes conventional medical thinking with a new comprehensive view of what germs do. Some people worry about dangerous germs "going global." In most cases it is already too late. The most dangerous germs among us have already been disseminated globally. Ewald explains how evolution in this worldwide environment makes some germs turn nasty while some become harmless. Most importantly, he shows how we can work together to master our modern infectious plagues by controlling disease evolution. He reveals that we live in an ecosystem of microbes, and we must understand them to avoid their deadly damage.
Plague Time confirms that conventional medicine is facing a revolution. Addressing the frightening reality of the pathogens in human society today, Ewald's urgent, firm message is that the plague time is now.
- Free Press
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Introduction: The Culprits
What are we to fear in this scientific age? Nuclear war? Overpopulation? Drunk drivers? No doubt these are reasonable fears. But threats to our health have a special place in the human psyche. Surely the horror of deadly plagues able to carry away incomprehensible numbers of people has been one of our greatest fears, and certainly is now. But this book is not about the infectious diseases on which the popular media have focused. It is not about the infectious threats to the rich countries from the poor countries of the world -- the Ebola and West Nile viruses that captured headlines during the 1990s are in fact minor threats. The balance of evidence indicates that the major infectious plagues are not emerging from an African jungle. They are already here, embedded in every society, in rich and poor countries alike. In fact, they have been here for centuries, even millennia. They are as deadly and painful as the sensationalized plagues, but they have spread more insidiously and imperceptibly -- they are slow-motion plagues that are difficult to recognize and difficult to control. The flash-fire outbreaks that make the headlines usually burn out on their own. The serious infectious plagues aren't so easy to escape.
The plague of ancient Athens in 430 BCE, which Thucydides reported, the bubonic plague that transformed the society of fourteenth-century Europe, and the 1918 flu pandemic, which killed more than twice as many people as the weapons of the First World War, were all dreadful scourges of our past. Hardly any sane person thinks that we are suffering from any such calamity now. But we are. We live in a plague time that only a few thoughtful scientists have grasped. Our time of plague will continue for at least the next several decades, even if researchers are unusually clever. The major uncertainty is just how many infectious plagues are smoldering along, consuming the oblivious -- those people who think that their bodies are just falling apart from the wear and tear of life. There are certainly several such infectious plagues; there may be many more. A substantial proportion of the pain and suffering that occurred at the dawn of this new century will, I believe, become recognized as the result of long-standing, slow-burning plagues that are infectious but were not generally accepted as being infectious in the year 2000.
This view may seem disturbing and even more frightening than the idea of nasty Ebola-like viruses waiting to catch a plane to London's Heathrow airport, or New York's JFK. But there is good news. Infectious diseases usually have vulnerable underbellies, and recognizing a disease as infectious is one of the most important steps toward discovering its vulnerability. The agents of disease, those enemies within, are often difficult to identify. They are usually invisible and their behavior is deceptive. Although modern medicine can recognize some of these enemies, it has only a few clues about most of the others. The unknown majority are swept under the risk-factor rug, which generates a lot of tabloid journalism -- Does drinking some red wine lessen your chance of heart disease? Will holidays in the south of France make you live longer? Should you eat margarine or butter? -- while skirting the crux of the problem. We need to understand causes if we are to solve the big health problems.
When major problems are solved, people get a smug sense of superiority over previous generations who failed to recognize what has become an obvious solution. It now seems obvious that surgical instruments should be sterilized before surgery, that water supplies should be filtered and chlorinated to protect against diarrheal diseases, and that condoms can protect against AIDS. Soon it will seem obvious that peptic ulcers are caused by bacterial infection and can be prevented by antibiotic treatment. The task of the present is to recognize that which will be obvious to future generations. This task often requires a mix of skepticism and creativity -- skepticism to discern dogma, and creativity to develop alternative explanations that may not fit with the received wisdom. Failing to get this mix right leads to wasting time and resources on the wrong culprits. Bad genes and bad environments have often been falsely accused, or, at least, they have taken more than their share of the blame. Viruses and bacteria are the primary offenders.
In the mid-1970s I learned a lesson about identifying culprits while I was cutting my scientific teeth, conducting experiments on the territorial behavior of hummingbirds. The study was conducted in one of the dry riparian canyons that were ubiquitous along the coastal counties of southern California before they were transformed into a patchwork of housing developments.
Although there were fewer people in the greater Los Angeles area then, there was no shortage of troublemakers. These were the stomping grounds of the infamous Manson "family." After having a pair of binoculars stolen from my well-worn 1967 Volkswagen beetle, I began keeping a wary eye out for the bad guys. Weeks later, after tuning up the bug, I gave it a quick test drive down the canyon. When a car passed by going the other way, I thought it best to turn around and return just in case. I arrived at my makeshift outdoor work site just in time to stop someone walking away with my tool box: "Sorry, man! I thought that somebody just, like, left it here, man." "Right," I thought, as I vowed to increase my vigilance against thieves.
But my real lesson in vigilance came from a trickier case. The experiments on territorial behavior that I was conducting involved the provisioning of artificial flowers by infusion pumps. The pumps delivered a sucrose solution through a long tube that stretched from a syringe to the artificial flowers from which the hummingbirds would feed. As each pump slowly squeezed the syringe throughout the day, a flower was supplied with the solution. The mechanics sound simple, but Murphy's Law applies with great force to any experiment run outside the walls of a laboratory. After several exasperating problems imposed by weather, friction, evaporation, and the hummingbirds themselves, all was finally working well. Then, midway through an experiment, the vandals struck. When my assistants and I arrived to gather data one morning, the tubing to each flower had been sliced to pieces. Hoping that the act was just an isolated event, we replaced all of the tubing, wrote a threatening sign to ward off the troublemakers, and resumed the equilibration period to allow data collection on the following day. When we arrived in the morning, we found the tubing cut to pieces again. Exasperated and angry, we again repaired the damage, and I wrote a more severe warning about the consequences of interfering with government-supported research, adding that violators would be prosecuted.
Under the heavy influence of adrenaline and testosterone, I returned to the site before dark, thinking that I would wait there and scare off the creeps, hoping that they were little creeps and thinking about what kind of weapons I might be able to improvise if they turned out to be big creeps -- the rocks in the streambed perhaps. I was too late. The vandals had already been there, but I must have interrupted them because only a few tubes had been cut. I sat down with tubing in hand next to my impotent warning signs, trying to think what my next escalation should be, keeping an eye and an ear out for anyone who had not yet escaped. Looking at the tubing, I noticed that, strangely, each cut had been made at the same slight angle from perpendicular. Parallel to each cut was a thin scoring of the tubing; it was just one sixteenth of an inch to the side of the cut edge and spanned only half the circumference of the tubing. Having cut the tubing with scissors many times, I realized that scissors did not make that kind of parallel mark. Nor would a knife. Then I guessed, correctly as it turned out, what implement would. I looked around slowly and carefully, and there, near some willows on the opposite side of the stream bank, staring right back at me, was the vandal: a brown towhee. Between its eyes was the destructive implement. Adapted to breaking seeds, that bill could make short work of the strange, long, squishy food with the drippy, sweet reward. The edge of the lower bill severed the tubing as it pressed up against the inside of the upper bill, while the edge of the upper bill left the telltale scoring just next to the cut. I looked back at my warning sign, feeling foolish about threatening a bird with prosecution.
My resolution of the problem had been delayed because I jumped to the wrong conclusion about its cause. Had I thought more broadly about the spectrum of possible causes, I could have resolved the matter much more quickly. On the bright side, it did not take me decades to figure out that my original line of thinking was leading me down the wrong path; and thousands of people did not die as a result of my misguided reasoning.
Unfortunately, the same cannot be said for medicine. Thousands suffered and died because antibiotic treatment of peptic ulcers was generally recognized in 1995 instead of 1955. Thousands more probably suffered and died over a similar period because cervical cancer was treated as bad luck rather than a preventable sexually transmitted disease. It would be gratifying if we could be confident that these oversights were a thing of the past, that lessons had been learned and the health sciences now objectively consider and present the spectrum of feasible explanations for the cause and control of diseases. But the record does not support this optimistic view, not when we assess the last two centuries of medical progress, nor when we assess the last two decades. We have no reason to think that suddenly in the year 2000 the mind-set and the biases have changed.
Cancers, heart attacks, stroke, Alzheimer's disease, and infertility are like the acts of an anonymous vandal. Together they are the primary reason our life expectancy is what it is. Experts say that causation is multifactorial; they consider risk factors but shy away from considering primary causes. Infectious agents are sometimes mentioned, but they are often dismissed without justification. If the true culprit is not suspected, we have little recourse for controlling it. The possible culprits fall into three general categories. One is bad genes. Another comprises harmful noninfectious aspects of the environment such as radiation, noxious chemicals, and dietary imbalances. The third is infectious damage caused by viruses, bacteria, and other parasites -- culprits that medicine thought it understood and had under control a quarter century ago. This last category has been grievously underestimated.
Modern medicine is not nearly as far advanced as the textbooks and most physicians would have us believe. It is now more important than ever to identify the weaknesses and mistakes of our medical establishment, not for the purpose of attacking hardworking doctors, but rather to suggest ways to better understand the predicament we are in at the beginning of the twenty-first century and the range of options that we have at our disposal for overcoming the very present danger we face.
Copyright © 2000 by Paul W. Ewald
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Paul W. Ewald, professor of biology at Amherst College, was the first recipient of the George R. Burch Fellowship in Theoretic Medicine and Affliated Sciences. The publication of his Evolution of Infectious Disease is widely acknowledged by doctors and scientists as a watershed in the emergence of the new discipline of evolutionary medicine. He has been featured in The Atlantic, Newsweek, Discover, and Forbes.
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