Francesca Tomasi received her B.A. from the University of Chicago and currently researches tuberculosis drug targets in search for novel antibiotics.
The seventeenth century brought with it major scientific breakthroughs, from Galileo’s telescope in 1609, to Antony Leeuwenhoek’s microscope and visualization of bacteria in the 1670s, to Isaac Newton’s laws of motion in 1687. In the eighteenth century, we met the steam engine and the world’s first battery, which led us in the nineteenth century to build electric motors, take photographs of nearly everything, click away on typewriters, and make light bulbs for the very first time. In the 1900s, innovation and discovery accelerated with airplanes, cars, rechargeable batteries, satellites, cellphones, and computers. At the same time, advanced technology and biomedicine were espoused to usher us into the era of modern medicine with antibiotics, transplants, and sophisticated full-body imaging techniques. Today, in the twenty-first century, we take things like the Internet, global communication, smart phones, DNA sequencing machines, supercomputers, and antibiotics for granted. More people in the world right now have access to a cell phone than to a toilet. Technology exploded into our world today and continues to grow in every sliver of society.
This technological explosion comes from Moore’s Law: literally speaking, the number of transistors per square inch on integrated circuits (the building blocks of computers) has doubled every year since their invention, suggesting exponential growth. An
The age of exponentially-growing technology and its seemingly infinite new directions comes with the caveat that society does not behave the way its inventions do. Yes, it seems to in some parts of the world: look at major cities like Tokyo, Boston, Abu Dhabi, San Francisco, Seoul, and Shanghai, with their futuristic architecture, proficient transportation services, and impressive hospitals. Millions of people keep up with technology and reap its many benefits. They get smartphones and barely miss a single beat whenever something new happens or is discovered. They get their genomes sequenced in search for any hidden hereditary diseases. They get CT scans, MRIs, and x-rays when there is (and when there isn’t) something wrong. They undergo the most cutting-edge treatments when they get sick. They live healthier and longer, technology becoming essential parts of their lifestyle.
The problem is that Earth’s population is in the billions, not the millions, and this leads to something called a law of negative returns: the more you add to something, the more it will decrease growth and production. In our case this means that, in some instances, the more cutting-edge technology you apply to fix one problem, the more it marginalizes those who cannot afford to fix that problem using that kind of technology, and the more problems it creates. One population suddenly has fixed their problem, while another not only is unable to, but is also left behind because the mere existence of a solution leads to the conclusion that the problem itself has been fully resolved. No one really tries to (or feels the need to) come up with a better solution for that other population.
While I was writing this article, a notification appeared on my phone from CNN: “How rich do you have to be to breathe clean air?” The question seemed fitting for the purposes of my article, so I swiped right to read it. It was a piece about Beijing’s smog. The story opens with an anecdote of a woman who wakes up every morning and the first thing she does is check to make sure her daughter is breathing clean air. She then proceeds to make breakfast – with organic foods that she washes with specially-filtered tap water. Then she drinks specially imported bottled water. All in the name of minimizing the toxic effects of living in one of Earth’s most polluted cities. The anecdote wraps up with “[b]ut for Beijing's rising middle class and poorer residents, this high-end home equipment is financially out of reach.”
It’s great that there are resources to pollution-proof a poisonous environment. Technology has allowed us to purify contaminated food and water, and to protect ourselves from the potentially harmful microbes or chemicals that might otherwise taint our sustenance. Technology has allowed us to treat countless diseases that would otherwise kill millions every year, and to produce more food for people who would otherwise go hungry. Technology has allowed us to communicate, to teach, to push the boundaries of science, to take us closer to understanding the universe.
But sometimes we get ahead of ourselves with technology. We can “pollution-proof” Beijing with some great technology, but only if we buy a multi-million-dollar home and install several extra thousands of dollars’ worth of filtration systems and air purifiers. As the CNN article points out, China’s pollution problems come from a massive economic boom that skyrocketed the nation’s material wealth, and made several thousand people rich beyond their dreams, making it okay to continue producing a massive amount of pollution. The mass implementation of technologies to produce things at unprecedented rates allowed China to emerge as an economic sensation, exponentially elevating the country’s economy. The wealth that poured over the people at the head of these efforts enabled them to develop technology that in turn keeps them safe from the harsh environmental consequences of their innovation. Thus the rich got richer and stayed healthy, while the poor got poorer and sicker.
Today, nearly one third of deaths in Chinese cities are attributed to pollution. This presents a law of negative returns: the more you add to fix one problem, the more it marginalizes those who cannot afford to fix that problem, and the more problems it creates, because the problem has not been fixed for everybody affected. Instead of undergoing a major public effort to reduce smog in urban China to acceptable levels (a public health solution to a problem whose source we fully understand), individualized, elite pods of healthy escapes – purified apartments, bottled air imported from the UK, vacation homes in the countryside, private doctors – allow the bigger issue to propagate. A law of growing returns (China’s economy) is on a see-saw with a law of negative returns (the polarizing pollution problem).
The same is true in medicine. There are some incredible advances in research that have opened the doors to so-called personalized medicine. We have identified specific genes, environmental and behavioral risk factors, and pathogens that are responsible for many acute and chronic conditions. We have ways to directly visualize bacterial infections raging their way through somebody’s body, and are working on ways literally to steer the right antibiotics to vulnerable sites. We have discovered ways to (eventually) implement gene editing to mitigate people’s risk of getting certain types of cancer, autoimmune disorders, or infectious diseases. We can grow organs and perform rejection-free transplants. We have at-home sensors and personal health-monitoring devices that sync with our smartphones and our doctors’ computers. Robotic surgeons help minimize risks inherent to human nature and boost survival rates for complicated procedures. Nanotechnology lets us deliver drugs or sensors throughout the body for therapeutic purposes. It’s amazing.
In our journey to push the boundaries of science and medicine, however, we seem to have cast aside – perhaps temporarily – the idea of access. Everybody in the world would benefit from the medical tools named above. But what percent of the world will realistically get the opportunity? Consider tuberculosis. According to the WHO, it is one of the top ten causes of death worldwide, but over 95% of TB deaths today occur in low- and middle-income countries. With the advent of antibiotics to treat TB, nearly 50 million lives have been saved since the year 2000, yet 1.8 million people still died of TB in 2015 and another 10.4 million people fell ill with it. Now, drug resistant tuberculosis is on the rise, with nearly half a million new cases in 2015 bearing this label. This means that current antibiotics are not sufficient, and stronger diagnostics are essential to identify drug resistant cases as early as possible to prevent further spread.
In 2010, the WHO endorsed a cartridge-based nucleic amplification test called GeneXpert to rapidly diagnose cases of drug resistant tuberculosis. The test works by using PCR (polymerase chain reaction), a technique that amplifies specific DNA sequences to detectable levels. The Xpert MTB system purifies and concentrates M. tuberculosis from patient sputum samples, isolates the bacterial genomes, and uses PCR to amplify any known genes associated with certain types of drug resistance. While a drug-susceptible sample of TB will not have these gene sequences and will therefore not yield any detectable amplification, a strain that is resistant to rifampicin, for instance, will carry a certain sequence in one or more genes that the Xpert will detect and amplify. The test spits out results in 90 minutes, a major contrast from the usual 4-6 plus weeks it takes to diagnose TB infections. Xpert is listed as easy to use, and apparently requires little technical training to operate. In 2013, UNITAID invested $25.9 million to purchase over 220 Xpert machines and 1.4 million test cartridges for 21 nations across Africa, Eastern Europe and Asia.
Xpert TB has done well in many countries. The WHO has even published an interactive map indicating what nations have procured new TB diagnostics, which include regions with some of the highest rates of TB infection in the world. According to a review of the Xpert rollout, since 2011 over 16 million tests have been performed in 122 countries. The detection of MDR TB has furthermore increased at least 3-fold compared to conventional methods. However, the review also points to several significant gaps. The authors state that the rollout “has been hampered by high costs for under-funded programs, unavailability of a complete solution package…and lack of impact assessment.” Simply put, comprehensive training, quality assurance, implementation, maintenance, and an actual connection from diagnosis to treatment require more attention. Significantly improving diagnosis can help reform behavioral practices to limit the spread of disease, but without structured treatment implementation to follow diagnosis, cure rates will not increase on their own.
In some areas of high-burden tuberculosis where Xpert technology would help dramatically, boxes of Xpert remain untouched, accumulating dust. There are many reasons for this besides the logistical ones mentioned above: different cultures might subscribe to different theories of disease. They may have their own health practices that seem to work just fine in a crippled healthcare infrastructure that under-reports cases. They may not have reliable power sources in their clinics to keep the machine going consistently. Any glitch along the process will sacrifice the quality of diagnosis and possibly promote distrust or obliviousness to inaccurate results. This, in turn, fuels an epidemic rather than quenching it. We think we solved the problem of diagnosing drug resistant TB with sophisticated tools like the Xpert, but we really might have further marginalized some populations that would greatly benefit from a quick and dirty (I say that figuratively, of course) way to diagnose TB infections. In these populations, drug resistant TB continues to spread mostly unchecked.
These stories do not have to have sad endings. CNN’s article about China point to the Kuznets curve, a hypothetical “inverted U” relationship between environmental quality and economic development: once average per capita income reaches a threshold, the environment starts to improve. Right now, we are at a point in which per capita income is on the rise in China, as is environmental degradation. The upper class has reached a level of discretionary income that allows them to afford anti-pollution efforts. If or when the middle and lower classes reach the same point, the Kuznets curve threshold will be reached and everybody will be able to afford to do something about pollution: hit the problem at its source, and hold public leaders accountable for progress.
A Kuznets curve for medicine may also stand a chance. In wealthy parts of the world, privatized hospitals and pharmaceutical companies become richer with medical innovation. When they want to pour resources into preventives, diagnostics, and treatments, they can. The world is full of benefactors, charity organizations, and cooperative governments that genuinely care about global health and do their best to pour resources in areas of desperate need. Many individuals and companies around the globe have come up with brilliant ways to reduce healthcare costs and increase access to treatment for countless illnesses. The global burden of these diseases have been mitigated – and in some cases, completely eradicated. The problem is not a lack of desire to help, or a lack of resources to do so. The problem instead lies in the type of help. Sending hundreds of robotic diagnostics to rural Africa or India will be met with just as much skepticism as an American doctor at a research hospital being told to diagnose drug susceptibility in a TB patient by cycling through antibiotics until something works. Medical technology is amazing, and it saves hundreds of millions of lives every year. But an exponential growth in the power of medical technology cannot realize its full potential if its side effect is increased marginalization, or negative returns on the world’s overall health.
Will Parker is a first year medical student at the University of North Carolina at Chapel Hill.
In his 1947 novel, The Plague, French author Albert Camus explores what the flourishing of a microbe in many human hosts—and the response to that outbreak—can teach about the human existential condition. Through his characterization of the actions and philosophies of two main characters, Rieux and Rambert, Camus pits a tolerant humanitarianism against a stridently romantic individualism. A third characterization, that of the Yersinia pestis (the plague microbe) outbreak itself, helps frame this conflict with a symmetry that lends power to a possible philosophical synthesis, though it does not resolve it explicitly.
The protagonist of the novel is a physician, Bernard Rieux, who works hard to fight against the plague epidemic from start to finish. This quote from the narrator (who is later revealed to be Rieux) captures his dedication and the philanthropic attitude that underlies it well: “The essential thing was to save the greatest possible number of persons from dying and being doomed to unending separation. And to do this there was only one resource: to fight the plague” (p. 115-116, 1962 Time Reading Program special edition). As the novel continues, Rieux never balks at his increasing medical and sanitary duties, even as the plague outbreak death toll rises. Nor does he complain when the accompanying quarantine keeps him from his chronically ill wife (who left the city before the plague outbreak).
Camus foils Rieux with another character, Rambert. The latter is a journalist marooned in Oran (the French Algerian setting of the novel) after the plague quarantine begins. In contrast to Rieux, who from the first dedicates himself to fighting the plague, Rambert whiles away the first few parts of the novel trying to finagle a way through the quarantine regulations. Unfortunately for him, stolid bureaucracy and then criminal unreliability frustrate his attempts to escape the city and return to his girlfriend. In several conversations with Rieux (the two become friends as the narrative progresses), Rambert tries to justify his desire to escape to his exhausted friend. In one particularly passionate discussion, Rieux and Rambert outline their rival philosophical positions. Rambert rejects the idea of mimicking Rieux’s selfless behavior, arguing such work would be meaningless heroism without love: “Man is an idea, and a precious small idea, once he turns his back on love,” he says. In response, Rieux merely supports Rambert’s efforts to try to escape the quarantine and reunite with his girlfriend, emphasizing, though, that his own behavior is motivated by duty rather than heroism: “You’re right, Rambert, quite right, and for nothing in the world would I try to dissuade you from what you’re going to do; it seems to me absolutely right and proper. However, there’s one thing I must tell you: there’s no question of heroism in all this. It’s a matter of common decency... the only means of fighting a plague is—common decency” (p.142).
Camus juxtaposes those concepts, romantic love and duty, throughout the book. Rieux makes notes about the romantic couples of the city both before, during, and after the plague. As the plague ends, for example, he approvingly describes the joyful reunion of many couples separated by quarantine, noting that “...it was only right that those whose desires are limited to man and his humble yet formidable love should enter, if only now and then, into their reward” (p. 262). Poignantly, Rieux says so at a point in the plot not long after he gets news of his own wife’s death (p. 254). Despite this devastating romantic loss, the physician-narrator plays down his own emotional response: “Regarding his personal troubles and his long suspense,” the narrator says about himself at the near the end of The Plague, “his duty was to hold his peace” (263).
The driving philosophical conflict of the book, then, lies within these explorations of selfless duty and romantic love: is Rambert right to seek out his own happiness in love (making Rieux wrong for not making attempts to visit his own ailing wife before her death)? Or is Rieux’s sometimes maddeningly selfless and tolerant humanitarianism the correct path?
Camus never explicitly answers this question, but his characterization of a bubonic plague pestilence helps shed light on it. While Camus doesn’t explain much of the microbiology of the pathogen beyond its identity as plague (p. 30) (Y. pestis, is a gram-negative, facultative anaerobe, that needs to enter a host cell in order to reproduce), he does—in a literary way—characterize the epidemiology of the outbreak. When first confronting the idea of the bubonic plague breaking out in his city, Rieux imagines an almost poetic, somewhat romantic spread of disease and chaos, a picture informed by stories of ancient Greeks battling for room to burn their plague-killed corpses during an outbreak: "A picture rose before him of the red glow of the pyres mirrored on a wine-dark, slumbrous sea, battling torches whirling sparks across the darkness, and thick, fetid smoke rising toward the watchful sky. Yes it was not beyond the bounds of possibility…” (p. 54). When summarizing the actual reality of the plague after the fact, though, Rieux finds his initial impression badly mistaken. The plague, far from being terrifying and romantic, was methodical, organized, and untiring. “No, the real plague had nothing in common with the grandiose imaginings that had haunted Rieux’s mind at its outbreak,” says the narrator (Rieux), “It was, above all, a shrewd, unflagging adversary; a skilled organizer, doing his work thoroughly and well” (p. 156).
That last description could be just as well applied to Rieux’s dogged work fighting the plague as it could the disease itself. A symmetry exists here: the qualities of the best work against the natural evil of disease in The Plague, and the outbreak itself, have much in common.
Of course, the achievement that the methodical, enduring Rieux fights for, and appreciates, is the opposite of the misery-wreaking pathogen: it is the joy and romantic fulfillment of people like Rambert. Thus, The Plague never dismisses either character’s driving philosophy. It places value on self-focused human happiness (especially romantic happiness) while simultaneously arguing for the need for humanitarians to protect that happiness—and in so doing sometimes forgo their own fulfillment—when the times call upon them to do so. It’s a well-balanced moral insight from Camus.
Infective Perspective founder, writer, and editor Francesca Tomasi gives us an overview of several vaccine-preventable illnesses, as well as how their preventive immunizations work.