Dennis Raphael Dennis.Raphael at
Sun Apr 27 17:53:02 PDT 2003

The past plagues are prologue

Epidemics always teach us something, says author ANDREW
NIKIFORUK. One SARS lesson is that we're too dependent on
hospitals - which can be scary places


Toronto Globe and Mail
Saturday, Apr. 26, 2003

When you learn that epidemic disease exists
in a country, do not go there; but if it breaks out
in the country where you are, do not leave. --

Epidemics, one of the real constants of human
history, are pretty rude teachers. SARS, a small
virus with a big stick, is a task master complete
with quarantines, travel advisories and foreign
devils. But it also comes with some surprising
messages -- and they are not the ones you are
hearing from the itinerant professional vandals
at the World Health Organization or the TV

The first lesson might bruise Ontario egos.
Plague historians generally agree that
spectacular die-offs are rare events. The
biggest global killer this century was the
influenza epidemic of 1918. It probably buried
anywhere between 40 million and 100 million
people. It flooded their lungs with water and
poured on pneumonia. It quieted entire
aboriginal villages and terrified prairie folk into
bundling the sick onto trains, a kind of moving

The ill generally got off dead. In the end more
than 50,000 Canadians died of influenza in a
single year. Now, that was an epidemic.

In contrast, SARS is a modest grave-digger, in
the last two months burying 18 Canadians and
more than 200 Asians. Hundreds more have
been sick and thousands have been
quarantined. Now, having a new cold virus
running amuck that can superinfect people with
an untreatable pneumonia is definitely bad news. So this virus is
definitely worth containing.

But SARS is not the plague of Athens ("No one expected to live to
be brought to trial for his offenses," wrote Thucydides). It is not the
Black Death (which dispatched nearly a quarter of Europe and
Arabia). Nor does it behave anything like smallpox. That mass
murderer burnt away the faces, eyes and internal organs of nearly
100-million aboriginals in one century.

But as epidemics have repeatedly illustrated, a microbe doesn't
have to be big to be bad. Polio never killed a lot of children but its
paralyzing abilities made it legendary. It also targeted the
squeaky-clean classes. So we all remember polio.

But Ontario needs to take its pulse again. SARS is a nasty
molecule, not an insurmountable mountain. Thanks to global trade,
global health organizations and the global media, the death of 16
people in one month can take on the weight of one thousand in one
week. (If a virus with 10 genes can unsettle Canada's industrial
heartland, just imagine what a bioterror attack might do!)

Epidemics are always about trade, politics and fear. In 1881, Egypt
clamped a tight quarantine on British ships coming from
cholera-infected Bombay, and for good reason. But the move
infuriated free-traders in England. So the Empire shelled Alexandria
and occupied Egypt. In our own century, China didn't want to say
much about SARS because it feared an imperial-like cannonade on
its trade and tourism. But it got one anyway -- and so did Toronto by
the virtue of international travel. Globalization works that way:

Whether ugly or just plain inconvenient, epidemics always tell us
something about the way we live. The Black Death, for example,
was an unabashed commentary on overpopulation, undernutrition
and peasant architecture (rat-friendly thatched roofs). Tuberculosis
is always a signal of much homelessness. Cholera wags a finger at
water quality. AIDS reminded us that sex is never safe and that
promiscuity has biological consequences. (Syphilis gave us the
same message, but as we developed treatments, we forgot it.)

The 19th-century bacteria watcher Rudolf Virchow correctly called
disease "life under altered conditions." He noted that epidemics
acted like grand warnings that told statesmen that a "disturbance
has taken place in the development of his people."

So what social disturbance is SARS illuminating? I'm no expert, but
I'd wager something is seriously out of sync in Guangdong province,
a place trying to move from the 18th century to the 21st in a hurry. Its
waters are putrid and its air is as smokey as 19th-century London.
The capital, Guangzhou, is home to millions of migrant workers who
sleep on the streets like homeless Cree in Winnipeg. Tellingly, the
1968 Hong Kong flu pandemic started in Guangdong. Microbes
recognize an opportunity when they see one.

But SARS is also highlighting another disturbance: the shoddy state
of infection control in our hospitals. For starters, the virus has been a
lazy opportunist that has largely dined on sick hospital patients. As a
result, about 30 per cent of the infected are hospital workers. In fact
most of Ontario's cases can all be traced back to one hospital. Here
in Canada, SARS is a hospital-acquired infection.

This is not an accident. Many ancient and recent epidemics,
including Ebola, have marked hospitals as formidable disease

Why? Hospitals, like nursing homes, are microbial feedlots.

Thanks to medical cost-cutters and promiscuous antibiotic use,
hospital infection control isn't what it used to be. As such,
Canadians generally now have a one-in-10 chance (according to
Health Canada) of acquiring an unwanted infection whenever they
visit an acute-care hospital. The rate at which patients pick up
woeful infections has increased by 36 per cent in the last two

Hospital-acquired infections now kill hundreds of Canadians and
more than 100,000 Americans every year -- and with barely a
headline. With the exception of animal feedlots and daycare
centres, no institution has done a better job of spreading
antibiotic-resistant bacteria to the greater community than hospitals.

Unsanitary facilities, unwashed hands and unsanitary instruments
account for most of these preventable deaths. SARS is a another
reminder that if you are not deathly sick, a hospital visit just might
change your prognosis.

Epidemics always do a good job of exposing these and other
vulnerabilities. SARS, for example, has underscored the sorry state
of Toronto's political leadership as well as the short-sightedness of
emergency response plans that assume health-care systems won't
get overloaded during an epidemic. It also illuminates the hopelessly
complicated nature of a just-in-time-economy that makes no
allowance for hazard. Nature doesn't make that kind of mistake.

SARS does not spell the end of Toronto or world trade. But it is an
economic upside-down mess for the golden horseshoe. China has
a true epidemic to worry about. A blazing economy there has altered
the conditions of life so rapidly that SARS won't be China's only
biological export.

But, like all epidemics, SARS will soon pass on. It could get uglier,
but I suspect it will just take up residence as a another chronic

In a strange way, the message of every epidemic is proverbial:
Wash your hands and love your children. Life is a gift and a gamble.

Andrew Nikiforuk is the Calgary-based author of The Fourth
Horseman: A Short History of Plagues, Scourges and Emerging

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