Tag: medicine

Sep 08 2023

Book review: Foreign Bodies: Pandemics, Vaccines and the Health of Nations by Simon Schama

My next review is of Foreign Bodies: Pandemics, Vaccines and the Health of Nations by Simon Schama.

The book is divided into three parts, covering smallpox, cholera and bubonic plague – in its late 19th century manifestation – and how vaccines were developed and deployed for these diseases. Waldemar Haffkine features heavily in the chapters on cholera and bubonic plague, for which he invented and delivered vaccines, and in some senses this is his biography albeit somewhat unfocussed with much additional material.

The first part covers the introduction of inoculation for smallpox to Western Europe in the early 18th century. This a process whereby a small quantity of the material from a smallpox pustule is introduced to small cuts in the skin of a patient who then falls mildly ill with the disease but is protected from further more serious infection. Voltaire appears in this section as a hook for some of the discussion – he was one of the early promoters of inoculation in France.

Terms are a bit fluid in this area but inoculation refers to the use of the live, unaltered bacteria/virus whilst vaccination refers to the use of a vaccine which is based on a weakened or even partial version of the disease causing micro-organism.

Smallpox was a serious disease in the 18th century, having apparently mutated to a more virulent, deadly form in the mid-17th century. This newer variant killed as many as 1 in 6 of those infected with many of those surviving showing significant scarring. It was indiscriminate, killing royalty as well as paupers. The inoculation process had been used by at least some communities in the Middle East, Africa and South America. The first chapter in this section is largely about the introduction of the idea of inoculation to polite Western European society. This met with some resistance – inoculation did not fit with the then current model of the smallpox disease (essentially the side effect of a bodily purging process), and it challenged the medical establishment coming as it did from a “foreign” country and, worse than that, was often practiced by women!

The second of the smallpox chapter covers the commercialisation of the inoculation process during the 18th century. This typically involved upselling preliminary treatments and post-inoculation care which was largely superfluous. It is interesting though that as part of this process the first clinical trials were conducted to test the efficacy of the process.

The second part of the book, on cholera, features Adrien Proust, father of Marcel Proust. Adrien Proust would become very involved in creating international the first public health organisations. Cholera had come to Europe around 1817 with pandemics killing many thousands recurring through the century. Proust senior had been a young doctor in the 1854 outbreak in Paris as a hospital doctor he would have seen 40% of patients die from this disease. At the time the cause of cholera was not known, it was assumed that it was a result of “filth” and unsanitary living conditions. This perhaps explains some of the Victorian efforts to install sewers and water systems, as well as the fact that living in crowded insanitary cities was simply unpleasant.

In the case of cholera, which is a bacterial infection discovered (quietly) by Filippo Pacini in 1854 and more famously by Robert Koch in 1883, sanitation and disinfection measures are a reasonable approach which has some benefits. There was commercial opposition to seeing cholera as an infection because that implied quarantines and the like which had a commercial impact. This attitude was to recur in the subsequent bubonic plague outbreaks in Indian and China which has more serious consequences since dirty water has no bearing on plague transmission. In fact we saw this argument regarding the COVID-19 restrictions.

It is in this part we first meet Waldemar Haffkine, born into a Jewish family in Odessa in 1860. He trained as a biologist working under Ilya Mechnikov, who would later win a Noble Prize for his work on immunity. Haffkine went on to the Pasteur Institute in Paris (Pasteur was still alive at this point), where he developed a vaccine for cholera. Haffkine had a an extensive file with the authorities in Odessa as a result of his activism in the defence of the Jewish community against repeated pogroms.

He tested his vaccine in India with minimal support from the colonial medical services. Reading between the lines it looks like his expenses claims were a key historical resource. To a degree he used the Indian population as one amenable for doing controlled trials of the vaccine due to their living conditions, and their status in the colonial system.

The part of the book on bubonic plague is a repeat of the chapters on cholera with Haffkine involved in the discovery of the plague bacillus, and the development and deployment of the vaccine, particularly in India. Here the story diverges a bit, the colonial response to plague was to apply sanitation measures up to and including burning down houses where infections had occurred. This, naturally, angered the local population and played some part in the rise of Indian nationalism.

Haffkine’s medical career was to effectively come to an end in the Indian plague vaccination programme. A vial of vaccine that had been produced in the facility he led was contaminated with tetanus leading to the death of nineteen vaccine recipients. The colonial Indian medical authorities were quick to place the blame on Haffkine although later investigations showed that the vial was most likely contaminated “in the field” (literally) and so was not at all Haffkine’s responsibility. He was eventually notationally exonerated with the support of Sir Ronald Ross (who won a Noble prize for his work on the transmission of malaria) but the damage was done and after some work on a typhoid vaccine he gave up his medical work aged 54.

Haffkine, in his later years, returned to his Jewish roots – arguing the case for Orthodox Judaism, and supporting a movement to make Crimea an area for training Jews in agriculture with a view to moving to Palestine. After the Russian revolution Jews no longer faced pogroms on the basis of their religion, they experienced persecution because the Soviet Union did not want anyone, regardless of religion practicing their religion.

I have mixed feelings about this book, it feels like it is trying to be several things at once – a history of vaccination for smallpox, cholera and bubonic plague but also a biography of Waldemar Haffkine with substantial chunks of not entirely relevant material also added. The long chapters don’t suit my reading style very well. At one point Schama manages a half-page sentence which I don’t think I’ve seen before in English! The book is clearly well-researched and written with some style but it doesn’t feel like a book to be read by the pool.

May 21 2022

Book review: Pale Rider – The Spanish Flu of 1918 by Laura Spinney

pale_riderPale Rider: The Spanish Flu and How it Changed the World by Laura Spinney is obviously very topical at the moment, it was published in June 2017 which makes it more striking how relevant it is than if it had been published in the last two years.

The book starts with an overall chronology of the 1918 flu pandemic before return to specific themes, generally through the medium of personal accounts or individual incidents. It is worth highlighting that the "Spanish" label is highly misleading, essentially the 1918 flu pandemic arose somewhere between the American mid-West, Northern France on the battle fields of the First World War or, a remote possibility, in China. Spinney discusses the link with viruses found in wildlife and livestock.

Initial estimates as to the death toll of the 1918 flu pandemic were around 25 million but these have been revised upwards recently to up to 100 million. Furthermore, the 1918 flu pandemic largely took place over September to December in 1918 with smaller waves in the spring of 1918 and in the following spring and with there were some variations by geography as to exactly when the worst effects were felt. So 1918 flu pandemic was a shorter, more devastating pandemic than the 2020 covid pandemic (which has killed around 3 million of a much large population). This was against the back drop of the First World War which killed more people in Europe than the pandemic, although around the world Europe was the exception with more killed by pandemic in all other continents.

The context for the 1918 flu pandemic was different too, the 19th century had been one of epidemics driven by industrialisation and the associated urbanisation. Amongst those were flu pandemics and 1830 and 1890. The 1890 "Russian" flu pandemic, was the first to be measured as a pandemic. The 1918 pandemic was at a time when the germ theory of disease was being developed, and the value of hygiene was understood. However, viral diseases were not well understood and it was not until the 1930s that the mechanism of transmission for flu was discovered with the first flu vaccines coming in 1936. It was not until the 1950s that it was confirmed as a viral disease. The symptoms of this flu pandemic were quite different from those of the covid pandemic with a mahogany colouration forming on the cheekbones that spread progressively until death, teeth and hair falling out and delirium (leading to suicide).

The health measures taken to address the 1918 pandemic were not that different from those used recently with sanitary cordons and quarantine used extensively. Religious ceremonies were exempt from restrictions in Spain leading to more cases. Closing schools was argued over with those in favour seeing schools as better for the monitoring of outbreaks, communication of health information, and offering better sanitary conditions, and food, to children. Starvation was a problem with supply chains effected from start to finish.

It is interesting to see the varying responses of Australia and New Zealand between the 1918 pandemic and the covid pandemic, Australia isolated in 1918, as it did in the covid pandemic but in 1918 they did not. The disproportionate impacts of the 1918 pandemic were also in evidence, with the recent Italian immigrants to the US, India and remote native American communities in Alaska very badly effected with mortality rates of up to 40%.

The pandemic had arguable impacts in world affairs, Woodrow Wilson had a serious stroke probably as a result of a bout of flu, and was not present to limit the war reparations against Germany.The independence movement in India grew. The flu impacted people in their twenties and thirties quite heavily, leaving behind a generation of orphans – their treatment was handled with new legislation by France and England. There was a post-pandemic (and war) fertility boom.

Despite the enormous death toll, even compared to the First World War, the 1918 pandemic appeared to have little impact on art and literature although scholars will look for signs of post-viral fatigue in paintings. Spinney argues this is because insufficient time has passed, noting that there are approaching 80,000 books on the First World War and but only 400 on the 1918 pandemic – but this number is growing rapidly. It has made me wonder about the lost siblings, in my grandparents generation which were never spoken of – similarly the absence of stories from fighting age men of the Second World War. Essentially these stories were too painful to handle at a human, personal level and the culture in the UK at least would not have been to speak about them. So it is left to historians and the passage of time for the stories to come to light.

A second factor, proposed by psychologists, is that pandemics lack a good story line with a clear beginning and end and a selection of heroes – unlike the First World War.

The Pale Rider is very readable, it is difficult to use the word "enjoy" regarding a book which tells of the deaths of 100 million people. I was struck by how relevant the 1918 flu pandemic was to our current situation with the disparate impacts depending on country and social conditions, the debates over school closures, the dedication of medical staff, the measures to address the pandemic and the debates over the compliance with public health measures. The covid pandemic is different – it has played out over a longer period, it has a far lower death toll, our medical knowledge is much improved, our world is much more connected but nevertheless The Pale Rider feels very prescient.

Nov 02 2018

Book review: Milk of Paradise by Lucy Inglis

My next review is of milk_of_paradiseMilk of Paradise by Lucy Inglis. I’ve been following Lucy Inglis on twitter since before she was writing books, so you can’t treat this as an unbiased report.

Milk of Paradise is the story of opium. It is divided into three parts, covering opium itself, morphine and heroin. Morphine and heroin are derivatives of opium so this collective biography makes sense.

The first part takes us back to prehistoric times and the origins of the poppy from which opium is extracted. The opium poppies grown today are domesticated, there is no wild opium poppy. The ancestral flower comes from Turkey where cultivation started in about 10,000BC. Traces of poppy mixed with henbane, another imported plant used to counteract the side-effects of opium, have been found in Britain dating back to 4000BC, where it could have only appeared through long distance trade. It always surprises me how far goods were traded across the prehistoric world.

The chapter moves on through opium in Roman and Greek times where descriptions are somewhat vague, to the Arab physicians of the 12th and 13th century who were clearly using it for anaesthesia for quite complex surgery. Similar preparations were used in medieval Britain, such as dwale – a mixture of hemlock, opium and henbane in wine. These appear to have gone out of usage.

The next section covers the the global trade in opium, particularly into the Far East. This picks up on some of the themes of The Silk Roads by Peter Frankopan. Opium had been introduced to China by Arab traders in the 10th century. As ocean going ships come into widespread use in the 15th century trade increased with tea, coffee and spices coming to Europe in the early years of the 17th century. By the 18th century half the Batavian (modern day Jakarta) spice trade was actually in opium.

The second part of the book, notionally on morphine a derivative of opium, covers the medical uses of opium preparations and addiction. Growing wealth in the 18th century in Britain led to people with sufficient money to abuse alcohol – the Gin Craze. This was paralleled with increasing signs of addictive behaviour in the use of opium. It was a problem in China too which the Chinese authorities tried to address in the face of military action by the British to maintain their trade in opium. Something of a theme in the book is the shameful behaviour of the British over selling opium to China, much of the 20th century has been spent on battling the “illegal” drugs industry. The 19th century was just as bad but the illegal drugs industry was replaced by the “legal” British trade of opium to China, something China tried to stop repeatedly.

The final part of the book covers the 20th century, prohibition and the rise of organised crime and gangs in the supply of drugs. Prohibition of narcotics is a relatively recent innovation in the West, it arose during the early years of the 20th century driven by the US who convened the 1912 International Opium Convention from which international prohibition legislation is derived. One gets the feeling the addiction starts to be seen as a problem when it effects women. Opium and its derivatives had long been used in medicine but the second half of the 19th century saw the growth of the pharmaceutical company who saw benefits in new formulations of existing drugs, the invention of new drugs and the promotion in treating all manner of ailments.

The rise of morphine and heroin was facilitated by the introduction of the hypodermic needle which provided rapid action, and convenience. The downside of this was the increased risk of infection, and addiction.

Also in the 20th century we see how war drives medical innovation, such as ambulances to recover casualties in the First World War, new surgical techniques, new anaesthetic methodologies, new antibiotics and new facilities for delivering medical care as close to the “front line” as possible (like the MASH units of the Korean War. Prohibition and the involvement of Germany as the opposition led to supply problems in the First World War.

In the period between the wars Germany expended considerable effort in innovating new drugs, one gets the impression that both the Allied and Axis forces were fuelled by amphetamines and other stimulants. In fact, more generally, one gets the impression that a large chunk of humanity has got through life in a drug-induced haze from time immemorial.

The book finishes with chapters on Afghanistan and “heroin chic”, the use of narcotics in popular and artistic culture.

I found Milk of Paradise very readable, the division into parts is not strong, much of the second part continues to talk about opium whilst notionally the chapter is about morphine. It is opinionated to a degree, which is no bad thing.