Infectious diseases and the dangers of complacency

November 5th this year marks the 125th anniversary of the death of Piotr Tchaikovsky. Undoubtedly the most famous Russian composer in history, his notable ballets include Swan Lake (1877) and The Nutcracker (1892). He was only 53 when he died, but perhaps of greater significance is the manner in which he met his demise. It is said that he drank water infested with cholera while eating his dinner; when his brother Modeste pointed out the dangers, the composer simply replied: “One can’t go tiptoeing about in fear of death for ever.” He died four days later.  

Twenty years later (almost to the day) saw the birth of another artist ultimately associated with infection. Albert Camus, the Algerian Nobel-Prize-winning author of The Plague (1947), was born on November 7, 1913. His philosophical masterpiece concerns the city of Oran gripped by a 10-month outbreak of infectious disease that leads to mass fatality, hysteria and ultimately the quarantine of residents and visitors alike. Those trying to leave are shot. The protagonist is Dr Bernard Rieux who, along with a band of medical colleagues, is challenged in both a practical and the existential sense as he battles to save thousands of lives. It is Rieux who first identifies the risk of plague, attempts to treat the first infected patient, and implores the authorities in vain to act immediately to prevent an epidemic. Undeterred by their complacency, Rieux heads the city’s auxiliary hospital and works long hours lancing abscesses and administering serum to relieve the suffering of his patients.  

Although The Plague is viewed by critics as an allegory of the German occupation of France during World War II, it also serves to remind us of an often-underestimated and more-modern Achilles heel. The World Health Organization sees antimicrobial resistance as one of the most urgent threats to global health, food security and economic development. Similarly, one might be forgiven for ruminating over the potential spread of deadly viruses. The Spanish influenza pandemic of 1918-1920 killed over 50 million people – more than perished in the preceding World War I. In the 1980s we worried about HIV. More recent threats have ranged from SARS to swine flu. And now, of course, we have Ebola haemorrhagic fever or Ebola virus disease (EVD) as it is now called. 

The latest outbreak of EVD in the Democratic Republic of Congo is causing particular concern because of a civil conflict taking place and impeding efforts to provide medical assistance and containment of spread. Transmitted initially to people from various wild animals, EVD first appeared in 1976 in two simultaneous outbreaks, one of which was in a village in the Democratic Republic of Congo near the Ebola River which gave the disease its name. A more-recent 2014-2016 outbreak in urban and rural Guinea, Sierra Leone and Liberia shed a sobering light on the dangers.

With an incubation period of two to 21 days, humans are infectious once they develop symptoms, which range from the flu-like, to bleeding, to renal and hepatic failure. EVD spreads through direct human contact with the blood and other bodily fluids of infected people, and also their infected clothing and bedding. Healthcare workers are particularly susceptible, adding to the challenge of effective containment. The average fatality rate is currently around 50%. A vaccine is emerging but, as treatment is still largely supportive, prevention and control of outbreaks through community engagement is essential, with case management, surveillance, contact tracing, good laboratory services and safe, dignified burials all paramount. 

If Tchaikovsky and Camus taught us anything, it’s that we should not be complacent.