Verified by 
Key points
- Fifty years ago, some epidemiologists thought people could soon stop worrying about infectious diseases.
- In today’s anxiety-ridden world, people are more focused on the likelihood of future pandemics.
- Scientists are up to the challenge, but our system of global governance may not be.
- It’s not only that countries and regions are increasingly interconnected—so are epidemics.
A few months ago, I discussed the idea of a technological fix. The term was introduced by Alvin Weinberg, a nuclear physicist and director of the Oak Ridge National Laboratory, a half-century ago. Trusting in science and technology to provide solutions for complex problems is convenient for politicians. It’s also reassuring for the rest of us. But can you push it too far? Let’s narrow the question down. Let’s just focus on medicine and specifically on controlling infectious diseases.
The epidemiologic transition
Another new term introduced a few decades ago was the epidemiologic transition. Some epidemiologists thought infectious diseases were of declining importance in the industrialized world. As the cause of death and severe illness, they were being displaced by so-called degenerative diseases. Thanks to increasingly affluent (and more sedentary) lifestyles, the prevalence of cardiovascular diseases and of cancers was increasing.
Today, there’s little talk of an epidemiologic transition. In the early 1980s, when the HIV/AIDS epidemic struck, it lost credibility. AIDS-related illnesses have claimed 40 million lives. Modern antiretroviral therapies cost around two thousand dollars per month per patient. Lifelong. It's no surprise that many people who need them don’t receive them.
In 2022 alone, more than half a million people died of AIDS-related illnesses. As new SARS-CoV-2 strains start to circulate, who needs reminding of the COVID-19 pandemic? Almost 7 million people worldwide have now died from COVID-19, including over a million in the U.S.
Nevertheless, it’s not difficult to find grounds for hope. Nearly half the world’s population is at risk of being bitten by malaria-carrying mosquitos. Over 600,000 people die of malaria every year, almost all in Africa. Now, after decades of work and endless disappointments, there’s hope. Vaccines are finally on their way.
When the threat of the SARS-CoV-2 virus became known, hopes were immediately pinned on the rapid development of a vaccine. The scientists didn’t fail us. They created the vaccines. But policymakers were reluctant to face up to problems that couldn’t be solved in any laboratory. The disruptions of social and economic life. The tragically unequal access to vaccines. Health services overburdened to the point of collapse.
The pandemic also points to problems of a different kind. Problems inherent in the way epidemics are tackled.
Tuberculosis
From the perspective of most North Americans or West Europeans, tuberculosis seems pretty remote. We associate it with pale and emaciated maidens in romantic 19th-century art. Or with the deaths of Chopin, Kafka, and Henry David Thoreau. But in the 19th century, tuberculosis was the greatest single cause of death in the Western world.
Most doctors thought a predisposition to tuberculosis was something inherited. If you’d been so unfortunate, onset of the disease could be triggered by cold wind, bad air, or injury to the bronchi or lungs. Few doctors believed it to be an infectious disease. That changed in the 1880s, when the German bacteriologist Robert Koch proved that it is caused by a bacterium. Koch’s discovery showed that the development of a vaccine should be possible.
Vaccination has helped
Forty years passed before there was a vaccine that seemed to work. The one known as BCG was developed at the Pasteur Institute in the French city of Lille. During World War 1, German troops occupied Lille, and research was paused. Only in 1921 was the vaccine ready for testing on a human volunteer. It was then made freely available, first to doctors throughout France. By the late 1920s, the use of the BCG vaccine was slowly spreading. Though not in the U.S. or Britain, where doctors weren’t convinced by it.
During World War 2, the prevalence of tuberculosis rose dramatically. In Europe, this was due to the displacements, homelessness, overcrowding, and malnutrition, which many countries suffered under Nazi occupation.
Tuberculosis is returning
Though there’s been a vaccine for a hundred years, tuberculosis still kills over 4,000 people every single day. This is partly due to the bacterium having adapted, developing treatment-resistant strains. But other factors are also involved. The COVID-19 pandemic made things worse. Tuberculosis diagnosis and treatment plummeted. This was particularly true in India, which has the world’s highest prevalence of tuberculosis. But it was also true of the U.S., which has one of the world’s lowest rates.
The latest available data on TB-related deaths also raise concerns that the COVID-19 pandemic might have had detrimental effects on TB diagnosis and disease progression, as TB deaths increased by 14 percent in 2020, representing the first increase in deaths from this disease since 2006.
Tuberculosis goes with poverty. It has always been most common in poor countries, in poor areas, in poor communities. Among U.S.-born citizens, people with lower incomes and less education are most at risk. But a large and growing share of tuberculosis in the U.S. is found among immigrants from high-prevalence countries. On arrival, symptomless but infected.
Interconnectedness
Who needs reminding that we live in an interconnected world? This interconnectedness highlights the limitations of the way we think about controlling epidemics. Yes, we need vaccines. We also need policies and mechanisms that get them where they’re most needed. Focusing on “our community” or even “our nation” isn’t enough. For policymakers, that demands thinking outside the box. There’s another box, less familiar. Our preoccupation with controlling the COVID-19 pandemic led to failures in tuberculosis diagnosis and treatment and increasing rates of infection.
I started with two new terms from the past: technological fix and epidemiologic transition. I’ll end with another, more recent neologism. Epidemiologists are now trying to grapple with interactions between epidemics, like that between COVID-19 and tuberculosis. They call these syndemics.
References
Dubos, R. & J. The White Plague. Tuberculosis, Man, and Society (1992) New Brunswick, N.J. Rutgers University Press
