BOOKS
Rethinking The Causes Of Disease Reviewed by Richard Levins one is the heady optimism of the 1960s and 70s, when public health communiqués predicted triumphs over one disease after another. At that time, infection in general seemed to be in retreat; applying the familiar weapons of pesticides, antibiotics, and vaccines with overwhelming force promised victory over pathogens; and rapid advances in molecular biology were expected to unravel cancer in short order. But malaria, cholera, tuberculosis, and yellow fever came back. The emergence of Legionnaires' disease, toxic shock syndrome, Venezuelan hemorrhagic fever, new kinds of diarrhea, nastier forms of familiar bacterial infections, and AIDS refuted the presumption that, in principle, infection had been licked. Increases in the incidence of breast cancer, asthma, and autoimmune diseases showed the problem wasn't limited to infectious diseases. Similar surprises in veterinary medicine and in plant pathology hinted at a more widespread phenomenon. When a large area of science is so completely caught by surprise, we have to seek the errors not in the details of one or other investigation, but in the conceptualization of the problem as a whole. We must step back, squint, and look for a different pattern. The major failings in recent years in the applied sciences of public health, agriculture, economic development, and nature conservation have been errors of narrow thinking. Problems were defined within tight disciplinary boundaries, so that even when many of their details were meticulously worked out, the solutions that followed didn't make things better. Pesticide use led to an increase in pests, antibiotics gave rise to new strains of pathogens, hospitals became foci of infection, expanding agricultural production impoverished peasants, and flood control increased flood damage. A flurry of recent books and articles— among them, Marc Lappé's "Evolutionary Medicine: Rethinking the Origins of
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mans, animals, and plants. Their article entitled "Disease in Evolution" (published in the Annals of the New York Academy of Science, 744, 1994) includes a discussion of the influence of social vulnerability and climatology on the emergence of disease. In a 1992 report on emerging infections, the National Academy of Sciences' Institute of Medicine concentrates on identifying emerging viral diseases of humans. Lappé limits the inquiry to humans, but uniquely unites infectious disease, cancer, asthma, and immune disorders within an evolutionary framework. Lappé, who is director of the Center for Ethics & Toxic Substances, Gualala, Calif., says his premise is simple: Most Tracking the evolution of an medical problems are problems of evolution. They are shaped by a long-term outbreak of disease that evolutionary history and they respond, catches science by surprise often very rapidly, to the forces of natural selection during the course of a calls for a more holistic disease and its treatment. The concept of evolution includes epidemiology changes that occur in the environment. Lappé discusses the ubiquity of new "Evolutionary Medicine: Rethinking environmental pollutants created by the Origins of Disease/' by Marc human activities and suggests they are Lappé, Sierra Club Books, 100 Bush St., challenging the human immune system 13th Floor, San Francisco, Calif. 94104, in unfamiliar ways. He describes how environmental disruptions such as de1994, 255 pages, $30 forestation bring humans into contact with pathogens that previously had other hosts. Such changes in the past Disease"—reflects a new recognition have led to major outbreaks of disease, that we have to think differently about he argues. "With hindsight," he writes, disease. All of these publications cover "we can see that the Black Death was a the evolution of infectious diseases in composite result of bringing a new inhumans, but each expands the scope of termediate host into contact with a disits discussion in a different way. Evolu- ease-causing organism and the creation tionary biologist Paul W. Ewald, for ex- of conditions ripe for the expansion of ample, focuses on the evolution of viru- the organism in the human population. lence in infectious diseases in "The Evo- When these conditions occur, a 'new' lution of Infectious Disease," published disease can arise." Newness, Lappé in 1994. Laurie Garrett links outbreaks of notes, depends on when the medical disease to societal events in "The Com- community an author belongs to recoging Plague," also published in 1994. At nizes a disease. Harvard School of Public Health, the inThe short-term evolution of pathogens terdisciplinary Harvard Working Group is the core of Lappé's analysis of both reon New & Resurgent Diseases combines sistance to antibiotics and changing patepidemiology with ecology, plant pa- terns of virulence. How drug-resistant thology, microbiology, sociology, and pathogens emerge is straightforward: mathematical modeling to study the Treating an infection vigorously with evolution of infectious diseases in hu- antibiotics may wipe it out, but if the
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BOOKS treatment is less strenuous or is discontinued, or if a weakened immune system causes the medication to be less effective, some pathogens more tolerant to the drugs survive and multiply. Lappé cites examples of pneumonia, tuberculosis, gonorrhea, malaria, meningitis, and other afflictions where bacteria developed resistance to a drug, and he shows how a therapeutic strategy that acknowledged evolutionary processes could have retarded the emergence of the bacteria. Cutting back on the use of preventive doses of antibiotics or bacteriostatic drugs, prescribing effective combinations of treatments, or making sure that a course of treatment was completed would have done the job, he explains. The author attributes current medical woes to "a special blindness to the natural forces that have shaped human disease and the consequences of adding powerful medical forces to the very organisms they are intended to control." Unfortunately, that special blindness is left unexplained, and readers are left with the impression that it is merely an intellectual failing. There's no suggestion in the book of how the subordination of research within the pharmaceutical industry—whose business is to produce marketable commodities—structures the organization of science, directs its agenda, and creates a culture in which this special blindness can flourish. The pharmaceutical industry supports research in both corporate and university labs with the goal of producing vaccines, antibiotics, drugs, and other agents for chemical intervention. Specialization among laboratories—even within the same company—contributes to the efficiency of development but detracts from looking at the problem as a whole. There is a bias toward treatment instead of prevention, which usually would involve more complex examination of social issues. Investors in industrial research prefer sure outcomes within predictable time frames, costs, and earning potential. Therefore, much more is published on chemical than on other approaches to cure and prevention. This colors the thinking about disease, so that an announcement that a disease agent has been identified is often followed by the expectation that a vaccine can be developed. Such efforts are not wrong, but they create an imbalance among disciplines and bias education in ways that 38 JUNE 19,1995 C&EN
discourage more holistic, long-range, multilevel strategies that don't promise marketable commodities. Universities are influenced by the industrial agenda through funding of faculty research and fellowships. Professors found or invest in research enterprises. Students study what is supportable and often expect employment in industry. Lappé is a thorough and severe critic of the failure of modern medicine to take evolution seriously. But he stops short of inquiring into the reasons for this, and the only remedy he proposes is that medical researchers should consider evolution. To confront the failures of public health in their entirety, epidemiology that's integrated over several fields is needed. Such an approach would break down the barriers among fields. It would see disease as developing simultaneously in the terrains of evolutionary ecology and socioeconomics. It would recognize that parasites are found affecting all groups of organisms and that we can learn general principles from the study of plants and animals that would help us better understand human diseases. An integrated epidemiology would explore the consequences of social ineq-
uity, academic fragmentation, urban growth, and the systems of beliefs about what causes populations to be vulnerable and which ones will be vulnerable. It would not rank science disciplines inversely by the size of the object they study—making molecules more important than populations or changing patterns of climate. It would look at multiple health problems in communities, rather than treat diseases as separate, autonomous objects. In examining the dynamics of epidemics, it would include changing levels of fear and the speed or slowness with which medical resources are allocated and withdrawn. And it would look self-critically at the history of its own ideas to discover what in the organization and prevailing philosophies of science made failure so easy. Such epidemiology doesn't exist yet, but there are gropings in the right direction. Toward this end, "Evolutionary Medicine" makes a positive contribution: It provides an unfamiliar, insightful, and broad-based view of disease problems that could lead to better use of existing treatments and guide research in ways that would reduce unpleasant surprises. , Richard Levins is John Rock Professor of Population Science at Harvard University School of Public Health. •
Vitrinite Reflectance as a Maturity Parameter: Applications and Limitations. ACS Symposium Series 570. Structure and Reactivity in Aqueous SoPrasanta K. Mukhopodhyay, Wallace lution. ACS Symposium Series 568. G. Dow, editors, χ + 294 pages. Ameri Christopher J. Cramer, Donald G. Truhcan Chemical Society, 1155—16th St., lar, editors, ix + 438 pages. American N.W., Washington, D.C. 20036. 1994. Chemical Society, 1155—16th St., N.W., $79.95. Washington, D.C. 20036. 1994. $99.95. World-Wide Limits for Toxic and Haz Sulfur Compounds in Foods. ACS Symardous Chemicals in Air, Water and posium Series 564. Cynthia J. MussianSoil. Marshall Sittig. xxxiv + 792 pages. an, Mary E. Keelan, editors, ix + 301 Noyes Publications, 120 Mill Rd., Park pages. American Chemical Society, Ridge, N.J. 07656. 1994. $98. 1155—16th St., N.W., Washington, D.C. Water-Based Paint Formulations. Vol 3. 20036. 1994. $79.95. Ernest W. Flick, xix + 502 pages. Noyes Publications, 120 Mill Rd., Park Ridge, Taxane Anticancer Agents: Basic SciN.J. 07656. 1994. $72. ence and Current Status. ACS Symposium Series 583. Gunda I. Georg et al. Paperbacks xii + 353 pages. American Chemical Society, 1155—16th St., N.W., Washing- Baculovirus Expression Protocols. Chris topher D. Richardson, editor, xiv + 418 ton, D.C. 20036. 1995. $99.95. pages. Humana Press, 999 Riverview Dr., No. 208, Totowa, N.J. 07512. 1995. Thermal Analysis: Fundamentals and $64.50. Applications to Polymer Science. T. Hatakeyama, F. X. Quinn. vii + 158 Chemical Sciences Graduate Finder 1994^-1995: Participating Master's and pages. John Wiley & Sons, 605 Third Doctoral Programs in the United Ave., New York, N.Y. 10158-0012.1994. States and Canada, xix + 659 pages. $54.95.
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1994. $54.95. Challenges in Synthetic Organic Chem istry. Teruaki Mukaiyama. i + 225 pag es. Oxford University Press, 200 Madi son Ave., New York, N.Y. 10016. 1994. $29.95. Dynamics of the U.S. Chemical Indus try. Sheldon B. Greenbaum. χ + 209 pages. Kendall/Hunt Publishing, 4050 Westmark Dr., Dubuque, Iowa 520041840. 1994. $40.79. Exploring QSAR. Vol. 1: Fundamentals and Applications in Chemistry and Bi ology. Vol 2: Hydrophobic, Electric, and Steric Constants. Corwin Hansen, Albert Leo. xvii + 557 pages, xix + 348 pages, respectively. American Chemical Society, 1155—16th St., N.W., Washing ton, D.C. 20036. 1995. $99.95, set. Grant Application Writer's Handbook. Liane Reif-Lehrer. xx + 472 pages. Jones & Bartlett Publishers, One Exeter Plaza, Boston, Mass. 02116.1995. $34.95. Introduction to Chemistry. T. R. Dick son, xvi + 589 pages. John Wiley & Sons, 605 Third Ave., New York, N.Y. 10158-0012. 1995. $20.95. Plasma Diagnostics. W. Lochte-Holtgreven. xvi + 928 pages. AIP Press, 500 Sunnyside Blvd., Woodbury, N.Y. 11797-2999. 1995. $60. Quantum Chemistry Workbook: Basic Concepts and Procedures in the Theo ry of the Electronic Structure of Mat ter. Jean-Louis Calais, xi + 204 pages. John Wiley & Sons, 605 Third Ave., New York, N.Y. 10158-0012. 1994. $39.95. Roth Collection of Natural Products Data: Concise Descriptions and Spec tra. Lutz Roth, Gabriele Rupp, editors, xxii + 500 pages. VCH Publishers, Dis tribution Center, 303 Northwest 12th Ave., Deerfield Beach, Fla. 33442-1705. 1995. $190. Understanding Polymer Morphology. Arthur E. Woodward, ix + 130 pages. Hanser/Gardner Publications, 6600 Clough Pike, Cincinnati, Ohio 452444090. 1995. $19.95.
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