Category: 21st Century

Cholera: Not Just The Poor Man’s Disease

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Often cholera is treated like a disease of the past, grouped together with the plague and smallpox which pose no serious modern concerns. While such an assertion is partially valid in that cholera no longer affects all of the modern world, unlike the plague and smallpox, it’s still prevalent and dangerous.

Cholera is an infection of the small intestine caused by the bacterium Vibrio cholerae. Infection can begin anywhere from 2 hours to 5 days after exposure to the bacterium. Symptoms usually include diarrhea, nausea and vomiting, and dehydration. Due to this symptom profile, cholera can quickly become deadly as the rapid loss of large amounts of fluids and electrolytes can result in death within hours.

In the past 200 years, there have been 7 cholera pandemics, the most recent being the 2016-2021 Yemen cholera outbreak. The third cholera pandemic, occurring between 1846-1860, is most frequently thought of when discussing the dangers of cholera.

In the 18th century, Great Britain was rapidly industrializing and by the 19th century, London was the largest city in the world due to mass migration from the countryside into industrialized towns. However, the city was unprepared for safely accommodating such large masses of people.

The city quickly became overwhelmed by human waste from the rapidly growing population who largely lived in the squalor of the overcrowded slums. Human waste soon overflowed into the gutters and the waterways. Until the COVID-19 pandemic, it was the worst outbreak in London’s history, claiming over 15,000 lives.

Illustration of London slum with subtitle 'A court for King Cholera'

At the time, the origin of the disease was unknown. The widely believed Miasma Theory held that cholera was the result of bad, stale air. Luckily one physician wasn’t so accepting of this theory. After systematically analyzing the people stricken by cholera in Soho, London, Dr. John Snow realized that all patients had one thing in common: a communal water pump. By removing the pump’s handle, the local outbreak ended.

While the solution of clean water seems like an easy fix, safe drinking water is a luxury in many parts of the world. 1 in 4 people worldwide don’t have access to safe drinking water with 6% of deaths in impoverished countries being the result of unsafe water. Each year, unsafe water is responsible for 1.2 million deaths. However, this issue is quickly hitting home in the United States as well.

Share of deaths from unsafe water sources - Our World in Data

Fresh water, “the oil of the 21st century” is quickly dwindling in parts of the United States due water stress from major population growth and changes in local climate. Since 2014, the citizens of Flint, Michigan are still without uncontaminated water.

While cholera is one example of diseases spread through contaminated water, other examples include dysentery, hepatitis A, typhoid, and polio. Furthermore, unsafe drinking water exacerbates malnutrition, resulting in childhood stunting which is also an important risk factor for death globally.

Number of deaths by risk factor - Our World in Data

For these reasons, maintaining and providing universal access to clean drinking water is a major global health emergency as the human population continues to grow and overwhelm Earth’s renewable resources.

 

 

 

PS. While researching, I discovered that there are two Cholera families in the United States dating to 1920. The last name of Cholera is most commonly found in India and 71% of Choleras live in Asia.

The AIDS Age of Misinformation

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On June 5 1981, the CDC published in its Morbidity and Morality Weekly Report a discussion of 5 cases of a rare lung infection known as Pneumocystis carinii pneumonia (PCP) in previously healthy gay mean. This is the first official report of what’s known today as Acquired Immunodeficiency Syndrome (AIDS).

Series of test tubes containing varying amounts of HIV particles and CD4 cells to depict the course of HIV infection.

AIDS is the final stage of Human Immunodeficiency Virus (HIV) infection. There are three stages of HIV infection: Acute Infection, Chronic Infection, and AIDS. During Acute Infection, people have flu-like symptoms while the HIV virus multiplies rapidly throughout the body attacking the highly important CD4 T-Cells of the immune system. Since HIV levels in the blood are very high, an individual in this stage is highly transmissible. During Chronic Infection, HIV continues to multiply but at such low levels that individuals may not have any symptoms. AIDS is the most severe stage of HIV infection as the severely weakened immune system leaves the body unable to fight off opportunistic infections-infections which usually pose only a harmless nuisance, such as the common cold. Once diagnosed with AIDS, individuals survive about 3 years without treatment.

It’s largely accepted that HIV evolved from the closely related Simian Immunodeficiency Virus (SIV), which spilled over to humans from Central African primates, further highlighting the dangers of the African bushmeat trade discussed in my previous post on the Ebola Epidemic. From Africa, HIV spread to the Western Hemisphere where it initially broke out in the gay community, whose lifestyle of casual, unprotected, multi-partner sexual activity allowed HIV to spread explosively. HIV transmits through bodily fluids-blood, semen, rectal fluids, vaginal fluids, and breast milk-meaning it can spread through unprotected sex, from mother to child via breast milk, through the sharing of drug needles, and from contaminated blood transfusions.

As of 2020, more than 36 million people worldwide have died of AIDS since the start of the pandemic. Although with proper treatment an HIV diagnosis is no longer a death sentence, there are still 37.7 million people worldwide living with HIV/AIDS as of 2020 who still experience the stigma of HIV diagnosis which dates to the pandemic’s beginning.

Since initial AIDS deaths were among gay men, the official name until 1982 for AIDS was ‘GRID’, or Gay-Related Immune Deficiency. With this early misstep, AIDS was quickly attached to what was, at the time, widely considered a sinful lifestyle. News broadcasts reporting on the pandemic used terms such as “gay cancer” and the “gay plague” as many openly blamed the afflicted, believing it was God’s punishment for living in sin. When it was shown that nearly half the people with AIDs weren’t homosexual men, homosexuals were further isolated as lepers capable of endangering “normal people” with their sin.

Figure 11: Misperceptions about HIV transmission held by small but notable minority of Georgians

This stigma was further bolstered by the misinformation on HIV transmission. Many thought, and still to this day believe that HIV can be contracted by touching an HIV-positive individual or surfaces the individual has touched. The responsibility for HIV misinformation is largely attributed to Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases, who speculated throughout the AIDS pandemic that close contact with AIDS-afflicted individuals could result in infection. The below interview of Dr. Anthony Fauci is from May 1983, where he speculates close contact is a method of HIV transmission despite the CDC’s certainty of all HIV transmission methods by January 1983.

The AIDS pandemic highlights the dangers of unfounded speculating and theorizing at times of high societal tension, especially during outbreaks of novel, deadly diseases. Such unproven speculations from trusted sources add fuel to the fire, resulting in long-lasting and impactful misinformation ingrained in society even decades later.

 

SARS Insanity: Doing the Same Thing, Expecting Different Results

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Since 2020, the news is inundated with information on the continuing SARS-COV-2, or COVID-19 outbreak. A similar occurrence occurred in early 2003 with the original SARS-COV outbreak.

Pourquoi le SARS-Cov-2 est-il plus infectieux que le SARS ...
The spike protein trimers of SARS-COV and SARS-COV-2.

As the acronym indicates, SARS-COV originated as a strain in the coronavirus family, which is also home to the common cold viruses. The initial transmission of this strain was a zoonotic spillover from the bat population of the Guangdong province in southeast China (1). From there, SARS spread to Beijing, which at the time, had a population of nearly 13.8 million people. From Beijing, it quickly spread internationally, resulting in 8096 cases and 782 fatalities (2).

A SARS-COV molecule

The difficulty in tracking SARS was largely linked to its generic symptom profile nearly identical to the flu-fever, cough, chills, muscle aches, headache, and occasional diarrhea. The cause of SARS fatalities is it’s eventual progression to pneumonia (3).

The rapid spread of SARS internationally is accredited to superspreading: the transmission of a virus to at least eight contacts. Due to the initial lack of information on this deemed “atypical pneumonia” which spread through respiratory droplets that contaminated the air and surfaces, superspreading was most common amongst healthcare workers (4). One of the most notable being 64-year-old Dr. Liu Jianlun who, after checking into a Hong Kong Hotel for one night, infected seven people. Although he had less than eight contacts, one of the contacts was with a Canadian tourist who brought the virus with her back to Toronto where it infected 60 more people. Another three of his contacts brought the virus to Singapore, where it spread to more than 195 people. It’s estimated that nearly half of the world’s SARS cases could be traced back to Dr. Jianlun. Whilst it’s easy to simply blame poor public health initiatives and hospital safety protocols, healthcare workers wouldn’t have to contend with novel viruses without zoonotic spillovers (5).

SARS is largely believed to have spilled over from bats to humans in the Guangdong wet market. Wet markets are open-air markets which, in addition to selling domestic livestock, also sell wildlife. Although wet markets in larger cities are more hygienic, those of the smaller communities are known internationally for their unsanitary conditions. A recent analysis of 1725 game animals from wet markets across China found 71 mammalian viruses, including 18 potentially dangerous to humans (6). Wet markets aren’t unique to China as they’re also prominent in several other Asian, African, and Latin American countries(7).

UN: Live animal markets shouldn't be closed despite virus ...
An image taken at a Chinese wet market.

And just like the bushmeat trade of Africa, much of the Chinese population depends on the more than $73 billion wildlife industry(8). Furthermore, wet markets are historically engrained in Chinese culture. Chinese wildlife trade began in the 1970s after tens of millions of Chinese citizens died of starvation under Mao Zedong’s communist rule(9). Additionally, many of the goods sold are used in traditional Chinese medicine.

However, the further danger is the Chinese government’s seeming disinterest in creating long-term policy changes. Due to the SARS outbreak, wet markets were banned between 2002-2004(10). After everything settled down, they reopened until the ban following the avian influenza outbreak in 2014(11). Wet markets were once again banned in 2020 for the COVID-19 outbreak(12). Zoonotic viruses don’t disappear from wild populations during these temporary bans. Once the bans are lifted, the danger of zoonotic spillovers return. Furthermore, these bans likely diminish the potential immunity of the countless venders and marketers frequently exposed to these viruses. The continuous cultural significance of wet markets and the government’s lacking initiative to properly handle this complex public health issue create a fantastic breeding-ground for future zoonotic spillovers and novel outbreaks.

 

 

Two Birds With One Stone: Learning From Ebola

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Though the Ebola virus experienced a surge in American public awareness in 2014, the Ebola virus has plagued international public health since 1976(1). Ebola rightfully earned international concern as the RNA filovirus initially causes a symptom profile nearly indistinguishable from other infectious diseases like malaria, typhoid fever, and meningitis. However, the fever, fatigue, muscle pain, headache, and sore throat are soon followed by vomiting, diarrhea, rash, impaired kidney and liver function, and internal and external bleeding(2). Unsurprisingly, the average case fatality from Ebola Virus Disease (EVD) is 50% with the lethality varying from 25%-90% between strains.

Why Won't The Fear Of Airborne Ebola Go Away? : Shots ...
A microscope image of an Ebola virion

It’s believed that the original 1976 emergence of the virus in the Democratic Republic of the Congo was a zoonotic spillover: a transmission of pathogens from wild animals to humans. Due to the close contact between the African population and wildlife, it’s widely accepted that Ebola was introduced into the human population through contact with bodily fluids and organs of infected animals. Such close contact provides a virus with an ample opportunity to evolve into infecting human hosts. The booming bushmeat trade of Africa provides viruses, such as Ebola, with ample opportunities to evolve into human infection.

Despite its illegality, many African communities depend on bushmeat for sustenance(3). In the Southwest African country of Gabon, bushmeat makes up nearly 100% of individuals’ animal protein intake. Through the bloody, unsanitary process of hunting bushmeat on such a massive scale, the evolution of viruses into human hosts is practically encouraged. In addition to posing a public health risk, the over-hunting of gorillas, chimpanzees and other primates, elephants, fruit bats, and more contributes to the further endangerment of these species(4).

Africa poaching bush meat crisis facts and figures
South-western Africa bushmeat facts and figures. Map by Sam Papai.

Though the protection of these endangered species is very important in maintaining global biodiversity, it has failed to successfully convince African communities to give up an available food source and ingrained cultural custom. Some argue that before beginning efforts to eliminate the bushmeat trade, experts need to take an initiative to establish a relationship and trust with village chiefs and elders. From there, they could provide encouragement for alternative sources of protein. Experts could also research suitable alternatives so that convincing Africans to give up bushmeat isn’t convincing them to go without food.

However, others argue that such efforts would be a fool’s errand as bushmeat is too ingrained in African culture to eliminate the trade in this manner. These individuals instead emphasize the importance of information campaigns which warn against the consumption of clearly ill animals and which encourage greater sanitation. This suggestion is supported by the West African country of Liberia’s drop in bushmeat consumption from 81% to 16.5% in 2014 as a result of the Ebola outbreak. Clearly for some, the risk of succumbing to a lethal virus outweighs the convenience of bushmeat consumption. It’s evident the most effective initiative to truly undermine and eliminate the bushmeat trade is to convince locals it’s more advantageous to go without. By doing so and eliminating bushmeat trade, we can better safeguard international biodiversity and public health.