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Chapter Eight: Disease
Cities . . . were microbe
heavens, or, as British microbiologist John Cairns put it, “graveyards of
mankind.” The most devastating scourges of the past attained horrific proportions
only when the microbes reached urban centers, where population density instantaneously
magnified any minor contagion that might have originated in the provinces. Any microbes
successfully exploited the new urban ecologies to create altogether novel disease threats.
Laurie Garrett, The
Coming Plague
A thorough understanding of the AIDS pandemic demands a commitment to the
concerns of history and political economy: HIV . . . has run along the fault lines of
economic structures long in the making.
Paul Farmer, Aids and Accusation
In the halcyon days after World
War II, when everything seemed possible and the advance of science and economic prosperity
inspired government leaders and leading academics to predict a coming era of worldwide
peace and prosperity, medical professionals were predicting the end of infectious disease.
Universal health was set as a realistic and achievable goal. The U.S. Surgeon General in
1967 said it was time to close the door on infectious disease. There was some reason for
this optimism. As a result of a worldwide vaccination campaign, smallpox had been
completely eliminated, the last case in the world being diagnosed in 1979. Malaria, one of
the world’s major killers, had been reduced worldwide and even eliminated in some
areas by controlling the vector—the mosquito—that spread the disease and through
the development and massive distribution of curative drugs. Tuberculosis, the major killer
of the nineteenth century, was disappearing. The U.S. Surgeon General declared that
measles would be eliminated by 1982 with an aggressive immunization campaign. Jonas Salk
had discovered a cure for poliomyelitis, the scourge of childhood, and the development of
antibiotics promised to rid us of every infirmary from pneumonia to bad breath. Then, in
the space of a decade, everything changed.
AIDS was one of the shocks that changed universal
optimism to what Marc Lapp 1994 called “therapeutic nihilism,” an attitude
common today among hospital personnel that nothing will work to cure patients. But there
were other reasons for the change: the emergence of antibiotic-resistant strains of
disease; the reemergence of malaria, cholera, and tuberculosis in even deadlier forms; the
emergence of other new diseases, particularly Lyme disease, dengue-2, and hemorrhagic
fevers such as eboli that result in massive internal bleeding and have mortality rates of
up to 90 percent. Measles, supposed to be eradicated from the United States in 1982, was
ten times more prevalent in 1993 than 1983. These developments and others have required
medical researchers in biology, epidemiology, and anthropology, among others, to reexamine
the relationship between human beings and the microbial world, particularly those
pathogens that cause disease. It is clear that we underestimated the ingenuity of microbes
to adapt to our adaptations to them, and failed to appreciate how our patterns of social,
political, and economic relations affect the emergence and transmission of disease.
Each age, it seems, has its signature disease.
Bubonic plague in the fourteenth and fifteenth centuries emerged as a result of the
opening of trade routes to Asia, carried by merchants and warriors from the middle of the
then world system west to Europe and east to China. Syphilis spread in the sixteenth and
seventeenth centuries through increased sexual contact of people in towns and cities.
Tuberculosis was the disease of the nineteenth century, spread through the air in the
densely packed cities and slums of Europe, the United States, and the periphery.
As we shall see, AIDS is very much the signature
disease of the latter quarter of the twentieth century, serving as a marker for the
increasing disparities in wealth between core and periphery and the accompanying disparity
in susceptibility to disease. More than 98 percent of deaths from communicable disease
(16.3 million a year) occur in the periphery. Worldwide 32 percent of all deaths are
caused by infectious disease, but in the periphery infectious disease is responsible for
42 percent of all deaths, compared to 1.2 percent in industrial countries (Platt 1996:11).
Table 8.1 summarizes the major diseases
afflicting the world today, the number of people affected, annual mortality, and whether
the disease is on the rise, declining, or stable.
Table 8.1: Characteristics of Major Infectious Diseases, 1993
Estimates by Death Counts
| Disease |
Incidence (millions) |
Deaths Millions |
Trend |
Vector |
Symptoms |
| Acute Respiratory Infections |
248.0 |
4.1 |
stable |
Bacterium & virus, airborne |
Cold, sore throat, influenza, pneumonia, & bronchitis |
| Diarrheal diseases |
1,800.0 |
3.0 |
down |
Bacterium & virus, water & food-borne |
Frequent liquid stools, sometimes bloody |
| Tuberculosis |
8.8 |
2.7 |
up |
Bacterium, airborne |
Severe coughing, sometimes with blood, chest pain, exhaustion, weight loss & night
sweats |
| Malaria |
400.0 |
2.0 |
up |
Protozoan, mosquito-borne |
Fever, headache, nausea, vomiting, diarrhea, malaise, enlarged spleen, liver, renal,
& respiratory failure, shock, pulmonary & cerebral edema |
| Measles |
45.0 |
1.2 |
down |
Virus, airborne |
Rash and fever, encephalitis in rare cases |
| Hepatitis B |
4.2 |
1.0 |
up |
Virus, sexual contact |
Anorexia, abdominal pan, sometimes rash, jaundice, cirrhosis of liver (chronic
infection) |
| AIDS |
(AIDS) 0.6 (HIV) 4.0 |
0.7 |
up |
Virus, HIV, types 1 & 2, sexual contact, shared hypodermic needles |
Autoimmune dysfunction progresses from asymptomatic to lethal; any organ system can be
targeted. Initially, fever, weight loss, diarrhea, fatigue, cough, skin lesions,
opportunistic infections such as cancer and tuberculosis |
| Whooping cough |
4.3 |
0.4 |
down |
Bacterium, airborne |
Hacking cough, infection of respiratory tract, can cause pneumonia and brain damage,
even death |
| Meningitis |
1.2 |
0.2 |
stable |
Bacterium & virus, airborne |
Inflammation of meninges of brain & spinal cord |
| Schistosomiasis |
200.0 |
0.2 |
up |
Protozoan, snail-borne |
Cirrhosis of liver & anemia |
| Leishmaniasis |
13.0 |
0.2 |
up |
Protozoan, sandfly |
Skin lesions, inflammation & crusting, skin ulcers, tissue destruction in nose and
mouth |
The fact that each historical epoch has its
characteristic illness reveals clearly that how we live—the social and cultural
patterns at any point in time and space—largely define the kinds and frequencies of
diseases to which human beings are susceptible. The questions we need to ask are; what
do we do that exposes us to disease? What do we do that exposes others to disease? How do
we create the conditions for unique interactions between pathogens, their environments,
and their hosts? Furthermore, what features of human societies make pathogens more or less
lethal?
Many of the things we discussed in previous
chapters are relevant. For example, increases in population density clearly relate to the
emergence and frequency of disease, as does the division of the world into rich and poor.
The crowding into cities of rural workers and peasants as agricultural land becomes
concentrated in the hands of a few influences disease susceptibility. Public policy that
makes economic growth a priority and neglects health programs encourages the spread of
disease, as do International Monetary Fund structural adjustment programs in peripheral
countries that demand the cutting of health, sanitation, and education programs. The
alteration of the environment has enormous consequences for the spread and emergence of
disease.
Infectious disease, of course, is not the only
health problem we face. Environmental pollutants, often a direct outgrowth of
industrialization, cause sickness. For example, asthma, often aggravated by industrial
pollutants, is on the rise. Millions of people face malnutrition and starvation,
conditions that further expose them to disease. Commercially promoted products such as
alcoholic beverages and tobacco endanger health. Of the estimated 1.1 billion smokers in
the world today, 800 million are in the periphery. The World Health Organization reports
that smoking-related deaths in the periphery will rise from 1 million per year in the
early 1990s to 2 million by the year 2000 (World Health Organization, The Tobacco
Epidemic, 1995). Furthermore, as cigarette sales continue to fall in the core in response
to antismoking campaigns and state legislation, cigarette companies, with the support of
core governments, have intensified their efforts to sell their products to people in other
countries, particularly to women and the young. For example, the United States has used
free trade arguments to pressure other nations—Thailand, Taiwan, and South
Korea—with economic sanctions to open their markets to American cigarettes. In such
cases it is easy to see a direct connection between the capitalist world system and the
onset of disease. However, the relation that exists between the culture of capitalism and
infectious pathogens is often more subtle and hidden.
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