Introduction
Introduction
A little over a century ago, my six-year-old dad and his family lived in a small, wooden, dirt-floored cottage in a shtetl that straddled one of the main Ukrainian-Russian east-west highways. In 1914, the First World War started. The Russian army attacked Germany and fell into a trap. The Russian Second Army was virtually destroyed at the Battle of Tannenberg, and thousands of the surviving soldiers retreated. When they came through my father’s town, the fleeing Cossacks burned the family home to the ground. During the subsequent war years, the family crowded into one of the remaining cabins on the edge of the village. It was owned by an elderly Ukrainian who hadn’t left for mother Russia with his family.
During the war, no one bathed or boiled their clothes. Everyone’s garments and bedding contained body lice. One winter there was a typhus outbreak. The infectious disease is caused by a tiny bacterium (ricketsia) that lives in the lice. When the creatures defecate, their droppings itch. People scratch, tear their skin, and bacteria enter their bodies. One to two weeks later, the aching starts. Many become quite ill. They have chills, high fevers, an unremitting headache, and exhaustion. When my grandmother became feverish, she was also confused. A Russian army nurse who was making the rounds came by. The family was unable to hide the sick woman and the nurse summoned a wagon. It took my grandmother to the school house, the large hall full of beds where most died. My grandfather watched and cried as they carted her away.
“During the eight years between 1917 and 1925, more than 25 million people living in Russia developed epidemic typhus, and three million died.” Some claim epidemic typhus has caused more deaths than all the wars in history. My father always remembered his boyhood, and when I chose to go to medical school, he shrugged. Based on what he witnessed, he believed doctors know how to recognize and diagnose illness, but that’s all they can do. (In the 21stcentury, typhus is easily cured and prevented with the antibiotic Doxycycline.)
The human body knows how to mend itself and fight off infections, and there have always been healers and helpers. The first sign of civilization, according to anthropologist Margaret Mead, was a femur (thighbone) that had been fractured and healed. Repair and restoration takes time. Without help creatures with broken legs can’t escape danger and don’t survive.
Prior to the 1900s, mankind didn’t have the ability and tools needed to cure the lame and blind, turn around a lethal infection, remove a cancer, or give someone a new heart or kidney. The needed drugs, devices, and skills—“health care”—were created (or transformed) during the last 120 years. It’s a gift we received because we were born in the 20th and 21st centuries. It may be as common as the iPhone, the airplane, or the internet. We may take it for granted and feel like it has always been and always will be available when we need it.
But it has become expensive. In the last 50 years, some of us have had to deal with costly insurance, obscenely priced medications, and outrageous hospital bills. Many of the people in charge don’t believe health care is or should be a shared responsibility.
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The authors of the Declaration of Independence didn’t think health care was an “unalienable right that was endowed by our creator” and health care wasn’t one of the many rights that were added to the nation’s Constitution in 1791.
Back then, nursing care supported the ill and sped their recovery. Amputations prevented some deaths. But most of the treatments doctors employed were pretty awful. Consider—the December morning in 1799 when 67-year-old George Washington awoke desperately ill. He was retired and lived at Mt. Vernon. The previous day, Washington felt well and went out in the snow to “mark trees that were to be cut down.” Upon awakening on the day in question, he couldn’t talk and had trouble breathing. His wife, Martha, sent for one doctor, then another. She and her husband were two of the country’s richest people and obviously didn’t need subsidized care.
During the day, three prominent physicians came to their home and plied their trade. The doctors were among the country’s best and they worked hard. On four occasions, they bled the sick man and removed a lot of blood. His throat was swabbed, he gargled, his feet were covered with wheat bran, and he was given an emetic to induce vomiting. Nothing worked. When Washington’s breathing got worse, he dressed, thanked his three doctors, and made arrangements for his burial. That night, he died. (As related by his secretary Tobias Lear)
Before 1800, the educated elites relied on the teachings of the ancients, like the Greek physician Hippocrates, who believed that illness was “due to an imbalance of blood, phlegm, black bile, and yellow bile,” and the Roman Galen who dissected monkeys and wrote about their anatomy.
Mankind was not aware of the microscopic creatures who lived in, around, and on us until the late 1700s.
During the 1800s we gradually learned about their existence. We started believing and understanding that they were the source of many of our maladies, and we began to take precautions.
In the 1900s our abilities exploded: We learned how to safely transfuse blood. Hormones were isolated. Antibiotics and drugs that fought viruses and parasites were developed. Experts learned and taught others how to replace eye lenses that were opaque. Vaccines were crafted. Thousands of medical gadgets were devised. Surgeons were taught how to proceed after they cut a person open, and a large number of effective drugs became available.
In 1965, over 100 million Americans were introduced to socialized medicine—Medicare and Medicaid. Most loved it.
In 2003, the entire human genome was “sequenced.” Scientists determined the exact order, the way the 3 billion pairs of human DNA nucleotides (building blocks) lined up, and our ability to attack and “cure” genetic conditions got a big boost. The push and pull between medical care as a shared endeavor or a wealth-producing commodity started in the 1900s. It intensified over time. In the last half of the 20th century, “health care” increasingly became a major part of the U.S. economy and obstacles and inequalities were created. This book seeks to make sense of the wonders that were developed and the challenges we face.
In the pages that follow, I’d like you to accompany me up the miraculous, tortuous road medicine has traveled during the last 200 years, and get a more detailed understanding of what I’m talking about.
The typhus epidemic in a shtetl during the First World War.
www.ferdmanfredman.com 0.11 TYPHUS.pdf
The death of George Washington.
Morens DM. Death of a President. New Engl J Med. 1999:341;1845-1849. Pubmed: 10588974. https://www.nejm.org/doi/full/10.1056/NEJM199912093412413 https://doctorzebra.com/prez/z_x01death_lear_g.htm
Is Health Care a Right? By Atul Gawande. The New Yorker Oct 2, 2017
MEDICINE BEFORE 1800
Margaret mead
Hippocrates: https://www.ncbi.nlm.nih.gov/pubmed/10361669
Blood letting history
http://www.pbs.org/kqed/demonbarber/bloodletting/
Chapter One: Awakening to the Microscopic World
Van Leeuwenhoek
https://interestingengineering.com/the-father-of-microbiology-an-antonie-van-leeuwenhoek-biography
http://www.brianjford.com/a-avl01.htm
Edward Jenner and the first vaccination:
cowpox –smallpox
https://emedicine.medscape.com/article/1131886-clinical
https://online.ucpress.edu/abt/article/39/7/440/11436/Edward-Jenner-and-the-First-Vaccination
https://www.nlm.nih.gov/exhibition/smallpox/sp_variolation.html
http://www.sjsu.edu/people/ruma.chopra/courses/h174_MW_F11/s3/smallpox_GWarmy.pdf
https://www.nlm.nih.gov/exhibition/smallpox/sp_variolation.html http://www.sjsu.edu/people/ruma.chopra/courses/h174_MW_F11/s3/smallpox_GWarmy.pdfhttp://sitn.hms.harvard.edu/flash/special-edition-on-infectious-disease/2014/the-fight-over-inoculation-during-the-1721-boston-smallpox-epidemic/
Semmelweiss and hand washing
https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(14)60062-3.pdf
Microscopes—Zeiss
https://royalsocietypublishing.org/doi/10.1098/rsob.150019
https://www.zeiss.com/microscopy/us/about-us.html
https://www.zeiss.com/corporate/int/about-zeiss/history/carl-zeisshtml
Abbe took over for Zeiss.
According to Abbe’s calculations the wavelength of light determines the light microscope’s ability to see tiny objects and the magnification factor can’t be much more than 1,000. A number of parasites that had not, previously, been visible were identified. After Zeiss died in 1888, Abbe became the head of the company and, ahead of his time, he introduced an 8 hour work day, pensions and holiday and sick pay.
Ruska developed the electorn microscope and one the nobel prize in 1986
https://www.nobelprize.org/prizes/physics/1986/perspectives/
Pasteur
https://books.google.com/books?id=YNBjDwAAQBAJ&pg=PA25&lpg=PA25&dq=pasteurs+wedding+day&source=bl&ots=0lwF4g53mX&sig=ACfU3U1G-UjPjYi4kBzEI_lieShlRCztYQ&hl=en&sa=X&ved=2ahUKEwiquNS0vanoAhUFup4KHbjqBJ4Q6AEwFHoECBkQAQ#v=onepage&q=pasteurs%20wedding%2
LILLE
https://www.thelocal.fr/20171017/lille-why-would-anyone-want-to-live-there
KOCH
https://www.britannica.com/biography/Robert-Koch
Koch and tuberculin https://www.sciencedirect.com/science/article/pii/S1201971210023143#bib2
.https://www.sciencedirect.com/science/article/pii/S1201971210023143#bib23
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3916274/
https://www.sciencedirect.com/science/article/pii/S1201971210023143#bib23
https://www.nobelprize.org/prizes/medicine/1905/koch/biographical /
https://www.who.int/news-room/fact-sheets/detail/tuberculosis
Dzintars GothamFaculty of Medicine, Imperial College London, London, UK; et al. Estimated generic prices for novel treatments for drug-resistant tuberculosis Journal of Antimicrobial Chemotherapy, Volume 72, Issue 4, April 2017, Pages 1243–1252
Joseph Lister
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468637/
Florence Nightingale
Eminent Victorians by Lytton Strachey https://www.ncbi.nlm.nih.gov/pmc/articles/PMC292098/
Chapter Two: The Late-19th Century
John Snow and diarrhea in 1854
The son of a York farmer, Snow had moved to Newcastle, a northern English city located on the Tyne River when he was 14 and was an apprentice to an Apothecary- surgeon for 9 years. He then moved to London where he studied medicine. He became a member of the Royal College of Surgeons ten years before “the first case of Asiatic cholera” came to “the great city.” The illness arrived in the body of a seaman who died a few hours after the illness “seized” him. The sailor had been working on a steamer where “the disease was prevailing.” Shortly after the man’s death his body was removed from the room he had been renting and another man moved in. Eight days later the newcomer developed severe diarrhea and fever—cholera. Snow discussed their illness in a medical paper and argued cholera was not airborne. “He also wrote about the neighborhood keeper of a coffee shop who served glasses of water from the Broad Street pump along with meals. She knew of nine of her customers who had contracted cholera.”
Mostly a vegetarian Snow “occasionally” drank wine when he was older, but he continued to have “faith in the temperance cause.” He dressed plainly, never married, “and found every amusement in scientific books, and simple exercise.” He was “full of humorous anecdotes” and told them in an irresistibly droll style. His husky voice “rendered first hearings from him painful,” but when he guffawed “his good natured face laughed in every feature.”
http://www.johnsnowsociety.org/john-snow.htm
On the Mode of Communication of Cholera
by John Snow, M.D.
London: John Churchill, New Burlington Street, England, 1855
https://collections.nlm.nih.gov/ext/cholera/PDF/0050707.pdf
http://www.bbc.co.uk/history/historic_figures/snow_john.shtml
http://www.ph.ucla.edu/epi/snow/snowbook.html https://johnsnow.matrix.msu.edu/work.php?id=15-78-43
The Origin of the Haitian Cholera Outbreak Strain | NEJM
https://www.nejm.org/doi/full/10.1056/nejmoa1012928
Water
https://scadata.net/brief-history-clean-drinking-water/
Robert Crane biochemist
https://iubmb.onlinelibrary.wiley.com/doi/full/10.1002/iub.366
Cholera and Ganges delta
https://www.passporthealthusa.com/2018/02/the-history-of-cholera-and-the-ganges-delta/
Koch and cholera https://www.sciencedirect.com/science/article/pii/S1198743X14608557
Cholera in Haiti
https://www.nejm.org/doi/full/10.1056/NEJMp1012997
See one do one teach one
Morton demonstrates anesthesia in 1846 and Dr. Warren proclaimed “This is no humbug”
https://www.pbs.org/newshour/health/the-painful-story-behind-modern-anesthesia
Thyroid removal surgically Kocher .
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4206627/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3824781/
Thyroid extract
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3046199/
Iodine in food.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509517/#B17-nutrients-04-01740
Murray thyroid replacement
https://www.jameslindlibrary.org/articles/the-discovery-of-thyroid-replacement-therapyappendicitis
https://pubmed.ncbi.nlm.nih.gov/20391748/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1353017/
The first cholecstectomy https://jamanetwork.com/journals/jamasurgery/article-abstract/589001
Anesthesia and amputation civil war http://www.pbs.org/mercy-street/uncover-history/behind-lens/surgery-civil-war/ Appendicitis- history
Anesthesia and amputation civil war
http://www.pbs.org/mercy-street/uncover-history/behind-lens/surgery-civil-war/
Horsley brain surgery England https://www.neurosurgeryblog.org/2016/08/17/faces-of-neurosurgerys-founders-victor-horsley/
PARASITES AND VECTORS
Patrick Manson-vector parasitology
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3630944/
https://www.rcpe.ac.uk/sites/default/files/jrcpe_49_1_hussey.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2463920/?page=1
Malaria
https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-10-144
https://www.encyclopedia.com/people/medicine/medicine-biographies/alphonse-laveran
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825508/ https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-10-144
https://www.nobelprize.org/prizes/medicine/1907/laveran/biographical/
https://www.nobelprize.org/prizes/medicine/1907/laveran/lecture/
Richard Ross and mosquito transmission
https://www.cdc.gov/malaria/about/history/ross.html
https://www.britannica.com/biography/Ronald-Ross
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62019-3/fulltext
Patrick manson in london https://www.rcpe.ac.uk/sites/default/files/jrcpe_49_1_hussey.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2463920/?page=1
Chloroquine and malaria. https://blogs.sciencemag.org/pipeline/archives/2020/03/20/chloroquine-past-and-present
https://web.stanford.edu/group/parasites/ParaSites2005/Chloroquine/history.html
Artimisinen https://www.who.int/malaria/position_statement_herbal_remedy_artemisia_annua_l.pdf
https://www.nobelprize.org/womenwhochangedscience/stories/tu-youyou
Artemesian combination therapy malaria
https://www.nobelprize.org/prizes/medicine/2015/tu/lecture/ https://www.nobelprize.org/womenwhochangedscience/stories/tu-youyou
https://www.kit.nl/wp-content/uploads/2018/08/879_The-world-of-Artemisia-in-44-questions.pdf
https://www.mmv.org/newsroom/news/price-coartem-reduced-third-time-8-years
Yellow Fever
Dingler Suez canal http://www.kumc.edu/school-of-medicine/history-and-philosophy-of-medicine/panama-canal/french-panama-canal-failure.html
dingler suez canal http://www.kumc.edu/school-of-medicine/history-and-philosophy-of-medicine/panama-canal/french-panama-canal-failure.html
Walter Reed and Jesse Lazear– yellow fever
https://www.jstor.org/stable/6065?seq=16#metadata_info_tab_contents
https://www.medicalmuseum.mil/index.cfm?p=visit.directors.reed
https://onlinelibrary.wiley.com/doi/full/10.1111/jvec.12261 https://www.jstor.org/stable/6065?seq=4#metadata_info_tab_contents
https://www.historyofvaccines.org/content/us-army-researchers-discover-cause-yellow-fever
Mosquito eradication
“Lien Jih-ching (連日清) is a specialist in mosquito-borne diseases and helped eradicate malaria in Taiwan by reducing the number of endemic cases from more than 1 million to zero within a decade,” Chen said, adding that Lien helped Taiwan become the first nation in the world to be declared “malaria-free” by the WHO in 1965.
“People call me the ‘mosquito man,’” said Lien, who is nearly 90 years old.
Lien also helped to significantly reduce the prevalence of malaria in Sao Tome and Principe — an island nation in western Africa — as depicted in the second part of the documentary.
“The prevalence of malaria was about 40 percent in 2000 … after we applied mosquito prevention measures, the numbers of patients hospitalized for malaria in Sao Tome and Principe dropped to zero in 2003,” Lien said in the documentary.
The use of an insecticide called dichlorodiphenyltrichloroethane is credited with the eradication of malaria in Taiwan, but it was not as effective in Sao Tome and Principe, Lien said, adding that he instead used alpha-cypermethrin, which had proven effective in southern Taiwan against dengue fever.
http://www.taipeitimes.com/News/taiwan/archives/2016/07/14/2003651008 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011539.pub2/full
Schistosomiasis
Schistosomiasis — Assessing Progress toward the 2020 and 2025 Global Goals.
Schistosomiasis–assessing progress toward the 2020 and 2025 global goals
https://www.nejm.org/doi/full/10.1056/NEJMoa1812165
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964474/
Praziquantel for Shistosomiasis-bilharzia
https://www.nejm.org/doi/full/10.1056/NEJMra012396
https://www.emdgroup.com/en/news/ivory-coast-19-10-2016.html
who.int/news-room/fact-sheets/detail/schistosomiasis#:~:text=Praziquantel%20is%20the%20recommended%20treatment,initiated%20and%20repeated%20in%20childhood.
https://www.nejm.org/doi/full/10.1056/NEJMoa1812165
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964474
Praziquantel https://cdn1.sph.harvard.edu/wp-content/uploads/sites/480/2013/01/praziquantel.pdf
https://www.nejm.org/doi/full/10.1056/NEJMoa1812165
https://www.nejm.org/doi/full/10.1056/NEJMra012396
https://www.emdgroup.com/en/news/ivory-coast-19-10-2016.html
who.int/news-room/fact-sheets/detail/schistosomiasis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780935/
https://cdn1.sph.harvard.edu/wp-content/uploads/sites/480/2013/01/praziquantel.pd
https://www.nejm.org/doi/full/10.1056/NEJMoa1812165
The story of Lice and ticks is on the web site but not in the book.
LICE
In the 1800s some claimed the river flowing past Rouen smelled bad when too many in Paris flushed at the same time. Rouen borders the Seine River and is 80 miles closer to the ocean than the city of lights. It is the capital of Normandy, is known for the Monet paintings of its Gothic cathedral, and is the home of the ancient marketplace where Joan of Arc was burned at the stake.
It’s also the town where Jules Noelle was born in 1866. At age 29, after he studied in Paris and became a doctor. Then he moved back home and married 21 year old Alice Louise Avice. He got a job at the local medical school, but his position was not tenured, his colleagues were reluctant to accept his “wonky” Parisian belief that germs caused disease, and he was unable to hear well enough to use a stethoscope. His career was going nowhere when the French government came looking for doctors for Tunisia, their recently conquered colony. Jules’ brother was offered a job in north Africa and he declined, but 36 year old Jules applied for the position and was hired.
In Tunisia an illness called Typhus was a problem each winter. (The name comes from the Greek word tuphos or stupor.) People in the “overcrowded prisons, asylums, and tent villages” ran fevers, became confused, and sometimes died. When Jules arrived an outbreak “was raging in a native prison 80 kilometers south of Tunis/” The doctor in charge of health care was planning to visit the area and Jules asked if he could accompany him.” The night before the trip Nicolle coughed up blood and he decided to stay behind. The chief doctor and his servant, visited the prison, spent the night, contracted typhus and both died.
As one of the now senior physicians, Nicolle decided to learn more about the illness. He visited a hospital, and recalled stepping over the bodies of typhus patients who were awaiting admission to the hospital and had fallen exhausted at the door.” He noticed that sick people “spread the contagion “to others in the hospital waiting room but stopped contaminating others as soon as they bathed and dressed in a hospital uniform.” Nicole figured the clothes—more specifically the lice that lived in the clothes, had to be the vector that spread the disease.
He injected a chimpanzee with blood from an ill patient and a day later the chimpanzee was running a fever and was prostrate. “Nicolle then injected a toque macaque (Macaca sinica) with blood from the ill chimpanzee and two weeks later the macaque got sick. He transferred the lice that were feeding on sick macaques to other macaques and they got sick. Nicolle was unable to culture the offending organism in agar or broth, but he published his findings in 2009 and remained in Tunis where he became an important bacteriologist. As he aged Nicolle became philosophical and a nature lover. His deafness got worse, it was hard to be social, and he spent much of his non research time writing and publishing three novels: The Two Thieves, The Pleasures of Boredom, and Marmouse and his Guests. He was “Captivated by the town of Carthage” built near the ruins of a once influential and affluent city. Noelle was known to hold court and sip mint tea in the village of Sidi Bou at a café that overlooked the town. Carthage had once been the home of Hannibal the general who marched his troops and elephants across the Alps and almost reached Rome. Between 264 and 146 BC the ancient city-state fought three bloody wars with Rome. During the third war the Carthaginian troops were defeated and the town was thoroughly destroyed. At age 62 Noelle was awarded a Nobel Prize.
The germ that causes typhus belongs to a “type” of bacteria that replicates inside other cells but doesn’t grow on agar. Called Rickettsia, this type of bacillus enters the body through a skin scratch, gets into the blood stream, and infects the cells that line the arterial walls. The first illness proved to be caused by this type of bacteria was Rocky Mountain spotted fever. Infected people have headaches, fever, and a rash. Some become quite ill, and a few die. The name—Rocky Mountain fever–is a bit misleading because the disease affects people in many parts of the U.S. The groups of bacteria that only replicates inside cells are called Rickettsia after Thomas Rickets, a small town Illinois boy who showed how Rocky Mountain spotted fever is spread. As a young researcher Rickets spent four years working mostly alone and separated from his young family. He pitched a 10 by 10 foot tent in a hospital yard in the Bitter Root Valley of Montana, in a location where the population of ticks increased when the snow melted in spring. Rickets spent much of the research years catching and studying the vector that he thought probably spread the disease. One of the human families Rickets studied lived on a farm where large number of ticks thrived around the house, on trees, and on the ground. At one point, Rickets stained a sample of blood from a sick boy who had been bitten multiple times. Examining the slide Rickets saw the gram-negative bacillus that caused the illness. He was the first to identify the organism, and in 1910 he wrote a medical paper describing his findings. His discovery made him famous and later that year he went to Mexico to look for the organism that caused typhus. In the process of his research he developed typhus–and he died.
https://academic.oup.com/jid/article/189/5/938/810819
In 1930, the year after Nicolle won the Nobel Prize, Paul Müller, a Swiss biochemist working for the pharmaceutical company Geigy, discovered that dichlorodiphenyltrichloroethane (DDT) was highly effective for killing lice and other insects and seemed to be safe for man. Muller had become interested in chemistry when he was a high school student. As a teenager he “was often mocked by his peers and called, “The Ghost,” due to his thin and pale appearance” In later life he owned “a home in the alps, tended a small fruit farm, and took the children on early morning nature walks. In 1948 Muller was awarded a Nobel Prize. After it was discovered DDT was widely used in Europe and elsewhere and Typhus stopped being a major problem. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819868/
Ticks and tickborne diseases
https://www.nejm.org/doi/full/10.1056/NEJMp1911661
lyme
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3117402/
https://www.bayarealyme.org/about-lyme/history-lyme-disease/
Babesia
https://www.lymedisease.org/lyme-basics/co-infections/babesia/
https://www.nejm.org/doi/full/10.1056/NEJMp1911661
Enteric worms.
https://aeon.co/essays/medieval-people-were-surprisingly-clean-apart-from-the-clergy
Albendazole—high cost generic drugs
https://www.nejm.org/doi/full/10.1056/NEJMp1408376