Healthy Précis Quarterly

Healthy Précis Quarterly | Issue 28 | December 2017 | adarash.net | [email protected] Page 1

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Healthy Précis Quarterly Primer Simply put, “life” is nothing but conscious existence, in which health and disease are its two critical elements. Of

diseases known to humankind, infectious diseases are the worst. Causation is being connected to omen, miasma,

germs, the epidemiologic triad, and to multi-factorial causation – in that chronological order. Life is also a marvelous

and taxing journey, in which a protracted war and endless battles, against infectious diseases, are horrific realities

ever told inside “travelers’” stories – devastations of biblical proportions, transforming the social fabric, in their own

eccentric ways. Environmental sanitation and personal hygiene; developing antimicrobials, antitoxins, and vaccines

are being instrumental in the obvious decline of the burden of infectious diseases. Advances in guidelines and

technology help identify, track, and control infectious agents, safeguarding the complex journey. So far,

accomplishments are extraordinary, particularly in nations with high-income economies. While semi-similar patterns

are being seen, nations with low-income economies remain improving, but at slower than snail pace. Worldwide,

despite successes on record – resistant strains, emerging and re-emerging infectious agents, coupled with

population increase, social-economic-political instability, massive and frequent travel, and climate change – the war

continues protracted; the battles, potentially devastating, but winnable; and life goes on, nonetheless. As most

critical issues in life, infectious diseases are not only health issues, but human rights issues, as well – a question of

morality. Indifference is inexcusable! With that overture, you are cordially invited, for a conversation on “life,” as

you see it, in the context of infectious diseases.

As always – a coffee table conversation starter, with family and friends

Introduction Trying to define the word/term “life,” may be a

mistake, rather a challenge, if you will. Anyways,

here in the galaxy of HPQ, we consider life as a

conscious existence — living and non-living, the

surrounding universe, the known and unknown,

the objectives and subjective, actions, reactions,

interactions, communications, and the resultant

realities of presence.

Obviously, the state of a conscious existence

dictates, health and disease, as everybody’s

concerns. Living level of knowledge on health

and diseases is a survival tool, indispensable. To

that effect, conversation on the subject, with

colleagues, family and friends, will serve as

enabler. Based on textbooks and articles, in the

public domain — HPQ, our informal, ultra-

synoptic flyer, is here to further that intent.

Prior to the twentieth century, diseases like

cholera, diphtheria, poliomyelitis, tuberculosis,

plague, malaria and smallpox, among others;

were dominant causes of the burden of disease.

The burden of infectious diseases has been on a

decline since the dawn of the twentieth century.

By mid-twentieth century, major causes of the

disease burden in nations with high-income

economies, shifted from infectious to non-

infectious diseases. While similar patterns are

being noted, progress continues at a slower than

snail pace, and as such, infectious diseases remain

as major causes of the diseases burden, in

nations with low-income economies.

[“…It is time to close the books on infectious diseases,

declare the war against pestilence won, and shift national

resources to such chronic problems as cancer and heart

disease”: William H. Stewart, US Surgeon General, 1967]

Yet, infectious agents are all over [in the

environment and in/on our bodies ;) may evolve,

become resistant to treatment, and are easily

transmissible. That profile enables infectious

agents to emerge [SARS, HIV/AIDS, Ebola, Zika,

etc], and re-emerge [malaria, tuberculosis,

influenza, and measles, etc] on a continual basis.


-------—-————-—--———-—————-——-————-—--------------Panel Adarash, |December 2017 ---------—-——-—------------——————-————--— Moreover, population increase, massive and

frequent travel, deforestation, growing contact

between humankind and other animals, climate

change; social-economic-political instabilities;

poverty, and the lack of withstanding healthcare

systems – intensify the continual threat, on a

global scale.

The Journey Life, as a conscious existence, takes a marvelous and

taxing journey. Health and disease are part of the

inherent itinerary – in which countless infectious

agents, by default, come bundled in the natural

contract. It remains mystery, for how long the

journey continues, but we are here in time and

space. Therefore, to add structure to the rather

intricate subject matter, and for nothing much

but convenience, we put forward four segments

of concept transitions, around the dynamics of

infectious diseases – time zero to the present.

[1) Superstition to miasma, 2) miasma to germs, 3) germs

to the theory of epidemiologic triad, and 4) the theory of

epidemiologic triad to the theory of multi-factorial

causation]

Superstition to the theory of miasma:

Superstition, that attaches omen [good and evil]

to every surprise of the time – in its essence and

of its nature, was never much of a help in the

war and battles against diseases in general and

infectious diseases in particular. [It] nonetheless,

out of necessity, might have helped triggering

the inherent human potential, igniting the prime

“tinkering out of the box” phenomena – the first

fundamental jump onto the theory of miasma.

Short of prophesying on infectious agents and

contagiousity, miasmatic theory serendipitously

connects, of course firstly infectious diseases to

the surrounding environment – aka, “bad air.”

The theory of miasma provides the basis for

actions by sanitary reforms that result in initial

declines of the burden of infectious diseases.

The theory of miasma to germ theory: History

has it, a connection between germ and disease

was proposed far earlier during the sixteenth

century. However, it was during the nineteenth

century when Pasteur, Koch, and Snow are

regarded pioneers of germ theory, in their own

ways. Ever since, germ theory remains rooted in

science, playing transformational role in finding

disease causing microorganisms, life cycles, and

mode of transmissions; the bases for developing

antimicrobials, antitoxins, and vaccines – plus

prevention, control, and eradication strategies.

As result, most of the known infectious diseases

controlled, and the burden noticeably declined.

However, germ theory, possesses soft spot, in

fully explaining models of causation, and

criticized for simplifying [agent – disease,] the

more complex dynamics of occurrences of

infectious diseases.

Germ theory to the theory of epidemiologic

triad [agent, host, and the environment]:

Beginning in early twentieth century, the theory

of the epidemiologic triad came to rescue germ

theory, unfolding the complex dynamics of

infectious disease causation.

[Stallybrass: Principles of Epidemiology and the Process of

Infection, 1931: Three factors are coined as key in the

spread of disease – the host, the environment and the

reservoir. Am J Epidemiol, 2003; 157:856-857]

The theory of epidemiologic triad states, for a

disease to occur, the involvement of [agent,

host, and environment] is necessary. Meaning,

the mere presence of the “agent” is not always

sufficient for a disease to occur. In doing so, it

speeded up the efforts and successes in many of

the infectious diseases.

The theory of the epidemiologic triad however

falls short of presenting its applications in

complex scenarios, especially in the spectacles

of non-infectious diseases.


-------—-————-—--———-—————-——-————-—--------------Panel Adarash, |December 2017 ---------—-——-—------------——————-————--— The theory of epidemiologic triad to the theory

of multi-factorial causation: The theory of multi-

factorial (web of) causation refers to a chain of

causation, in which each link is a result of

complex actions and interactions of preceding

events – individual factors (component causes),

one or more causal pathway (sufficient cause),

and a component that appears in every pathway

(necessary cause)).

The theory of multi-factorial causation serves

well the fields of infectious and non-infectious

diseases that are likely to have complex diseases

processes – but still, the way the theory lends

itself to prevention and control measures is not

straightforward, to put it lightly.

On a related note, contributions of the four

consecutive industrial revolutions and precise

translations in the fields of health and disease

are astounding. From direct cell culture and

gram stain, to genomics and proteomics and all

the rest in between – from hardcopy registries

and hand calculations to big data and quantum

computing – advances in technology remain

pivotal in many aspects of transformations,

including in the prevention, treatment, control,

and eradication of infectious diseases. The ever-

evolving Koch’s postulates are still important.

[Genomics and proteomics have the potential to ((provide

accurate and rapid identification of infectious agents),

(determine specificity, sensitivity, resistance and

mutations), and (guide effective, specific, and direct

treatment options)) – vital in the fields of public health!]

Well, life goes on – and in a global aggregate,

every resultant moment of the future is a little

better than the previous. Else, we would not be

where we are today. In such a complex journey,

social order and responsible governance are

critical. When it comes to health and disease,

infectious diseases in particular – nations that

succeeded building a solid social order and

responsible governance are light-years ahead of

nations that are still engulfed in social,

economic, and political instabilities.

The War and the Battles As a conscious existence and complicated

journey, life, comes with a state of “war and

battles,” between humankind [leaving aside

other animals and plants for now,] on one hand

and risk factors in general and infectious agents

in particular, on the other – the war protracted,

and the battles endless and devastating but

winnable. While, the involvement of infectious

agents in the war and the battles is obviously

passive, the mission, for both parties essentially

is preserving their presence – survival!

[There is a long list of known infectious agents, including

((bacteriophages, plasmids, transposons), (Chlamydia,

mycoplasmas,) ricketsias, virus, bacteria, fungus, protozoa,

helminthes, ectoparasites, and Prions.)]

Infectious agents play a beneficial role in the

natural ecosystem, but some can be pathogenic

and cause disease. Generally, infectious agents

take comfort in a milieu that provides [sugar,

vitamins, minerals, and other chemicals,] invade

and multiply. Infectious agents evolve, including

through antigenic drift and shift; and may

develop resistance to treatment.

Inherently, the human body possess cascade of

immune mechanisms against invasions and

infections. Antimicrobials, antitoxins, and

vaccines are effective armaments. Individual and

herd immunity fortify the power necessary in

surviving the protracted war and the inevitable

and endless, battles.

Characteristically infectious agents are resolute,

and transmissible – directly or indirectly. Once

invasion or infection ensues and body’s immune

response triggered, signs and symptoms may

follow. Certain invasions and infections

however, may occur without producing any

signs or symptoms. Some infections may resolve


-------—-————-—--———-—————-——-————-—--------------Panel Adarash, |December 2017 ---------—-——-—------------——————-————--— by themselves, for others chronic inflammatory

process may ensue – immunization, prophylaxis,

and treatments are able to divert the dynamics.

Generally, infectious agents do not discriminate

by age, gender, and race, country of origin,

religion, or political affiliations. Seriously!

Up until the end of the nineteenth century,

plague, cholera, typhoid, tuberculosis, influenza,

and malaria among others, resulted in repeated

outbreaks with devastating loss of lives and

disruption of the social fabric. Transitions from

hunting to agricultural society, first industrial

revolution, the creation of towns, poor housing,

unsafe water supply, and unsanitary waste

disposals are factors critical fueling the

protracted war and endless battles, against

infectious agents.

Fast forward to the beginning of the twentieth

century, the burden of infectious diseases

started to show a significant decline, initially due

to actions taken through sanitary reforms, and

subsequently as result of the development and

use of antimicrobials, antitoxins, and vaccines.

The success was extra-ordinary in nations with

high-income economies, while nations with low-

income economies persistently lag behind.

Earlier in the twentieth century, in nations with

high-income economies, crossover of the major

causes of the burden of diseases happened from

infectious to non-infectious conditions.

Throughout the latter decades of the twentieth

and early twenty-first centuries, drug resistant

strains (malaria, tuberculosis) and cancer-

causing microorganisms (helicobacter pylori,

HBV, HPV) explained. Chronic diseases, including

various forms of cancer, increase vulnerability to

infections.

Overtime, prevention, treatment, and control

measures intensified and many of the dominant

infectious diseases drastically declined, and the

idea of eradication became within reach;

smallpox (1980), case in point – poliomyelitis

next in line, on a global scale.

During the early 1980s, the burden of infectious

diseases surges, in all nations, but even more in

nations with low-income economies, as result of

the emergence of HIV/AIDS. In nations with

high-income economies, infection-diseases-

death, from HIV/AIDS meaningfully declined at

the end of 1990s. Nations with low-income

economies are still struggling against a dual

challenge – the already established [endemic

and epidemic] levels of infectious diseases, and

the unabated emergence of HIV/AIDS.

Obviously, the twenty-first century inherited

increased risk of resistant strains, emergent, and

re-emergent infectious agents. What will come

anew is everyone’s guess. Massive and frequent

travel, population increase; social-economic-

political flux; the increasing contact between

humans and other animals, climate change, and

fragile healthcare systems make the war

protracted, and the battles still devastating,

nevertheless, winnable. Remember Ebola!

Bottom-line Grouping 195 individual nations into four broad

categories – (high-income, upper-middle-

income, lower-middle-income, and low-income)

economies; to present aggregated social,

economic, and political profiles; like measures of

health and diseases, will likely fall short of

reflecting realities, since individual nations

(within and without,) for all intensive purposes,

are heterogeneous.

Anyways, beginning in the twentieth century,

major causes of the disease burden in nations

with high-income economies have significantly

declined. Furthermore, a crossover between

infectious and non-infectious diseases was

observed as the major causes of the disease


-------—-————-—--———-—————-——-————-—--------------Panel Adarash, |December 2017 ---------—-——-—------------——————-————--— burden, resulting in a distinct transformation in

disease prevention and control strategies.

[“The top-ten causes of death in nations with high- Income

economies: ischemic heart disease, stroke, Alzheimer’s

disease; trachea-bronchus- lung cancers, COPD, lower

respiratory infections; colon and rectal cancer; diabetes,

kidney diseases, and breast cancer.” The WHO (2015)]

On the contrary, even today, endemic and

epidemic levels of infectious diseases, that are

already established, plus any emergent, and re-

emergent diseases, weigh more, as major causes

of the burden of diseases in nations with low-

income economies.

[“The top-ten causes of death in nations with low-income

economies: lower respiratory infections, diarrheal diseases,

stroke, ischemic heart disease, HIV/AIDS, tuberculosis,

malaria, preterm birth complications, birth asphyxia and

birth trauma, and road injury.” The WHO (2015)]

The profiles for the top-ten causes of death in

nations with upper-middle-income and lower-

middle-income economies appear to approach

that of nations with high-income economies.

Worth a repeat: Resistant strains, emerging, and

re-emerging infectious agents remain real

threats. Population increase and travel; social,

economic, and political flux; increasing contact

between humans and other animals, and climate

change make the threats, even worse. The risk

of epidemic and pandemic level of infectious

diseases remains high.

Furthermore, the burden of infectious diseases

(all diseases for that matter) is not only a health

issue – it is also a human rights issue. Failed

governance, prejudice, discrimination, and

stigma, intensify the already overwhelming

barriers that vulnerable segments of populations

shoulder. Protecting citizens from diseases,

infectious diseases included, is a prime purpose

of the existence of any governments.

[“(1) Everyone has the right to a standard of living adequate

for the health and well-being of himself and of his family,

including food, clothing, housing and medical care and

necessary social services, and the right to security in the

event of unemployment, sickness, disability, widowhood,

old age or other lack of livelihood in circumstances beyond

his control. (2) Motherhood and childhood are entitled to

special care and assistance. All children, whether born in or

out of wedlock, shall enjoy the same social protection.”

Article 25: The Universal Declaration of Human Rights,

1948]

All things that matter considered, and cognizant

of the astounding success in the fight against

infectious diseases; the journey remains

turbulent, the war frustratingly protracted, the

battles brutally devastating and endless, but

potentially, winnable – a dire picture that

persists hanging over the landscapes of all

nations, through the twenty-first century.

Yard of the Future

Eliminating social-economic-political instabilities; providing safe water and food supply, sanitary

waste disposal system, increasing availability of antimicrobials, vaccines and other disease prevention

and control programs are imperative — not only against infectious diseases, but also against all

rounded problems in society. Most importantly, the burden of infectious diseases (all diseases for that

matter) is not only a health issue, but also a human rights issue. Failed governance, prejudice,

discrimination, and stigma intensify the already overwhelming barriers that vulnerable segments of

populations shoulder. For a healthier and safer future and the elimination of immoral health

disparities – processes of civil society, specifically those focused on human rights, ought to be

exercised, explicitly and proactively, on a global scale. It is a small world, after all!

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