by Sean Martin
HIV seems to have been active in Kinshasa in the 1920s, when the country was under the control of the Belgians. A combination of a large population, a million migrant workers passing through each year, a thriving sex trade and good transport connections meant that Kinshasa became a disease factory.433 Then, around 1960, additional expansion of the railways spread HIV even further afield. And this was around the time when Arvid Noe was known to have visited Africa; a few years later, Robert Rayford was thought to have become infected, by person or persons unknown who had (presumably) recently been in central Africa. Both men seem to have been early victims of what would become the AIDS pandemic, as the disease slowly made its way out of Africa.
In its first quarter century, AIDS has infected around 65 million people, with around 25 million dead. The disease’s devastating effects make for grim reading. Nearly 40 million people are living with the disease, half of them women. Young people under the age of 25 account for half of all new infections worldwide. The majority of people living with HIV today are in sub-Saharan Africa. The disease still kills around 3 million people a year, half of them children. Around 6,000 people become infected every day. Africa has 12 million AIDS orphans. In North America, 1.4 million people are living with AIDS. HIV also has links to tuberculosis: people are more likely to get TB if they already have HIV. Between 1986 and 2006, there was a five-to-ten fold increase in TB cases worldwide.434 Just over half of all AIDS deaths have been in Africa.435
As the chief epidemiologist at Kampala’s Mulago Hospital said, ‘It all started with a rumour. Then we found we were dealing with a disease. Then we realized it was an epidemic. And, now, we have accepted it as a tragedy.’436
Lifestyle Diseases
In 1967, the US Surgeon General William H Stewart ‘would be so utterly convinced of imminent success [in public health campaigns against disease] he would tell a White House gathering of state and territorial health officers that it was time to close the book on infectious diseases and shift all national attention (and dollars) to what he termed “the New Dimensions” of health: chronic diseases.’437 If AIDS could initially have been seen as a gay lifestyle disease, then many of the chronic diseases Stewart wanted to see action on in 1967 could also be seen as lifestyle diseases. The latter half of the twentieth century saw a huge rise in the incidence of cancer, heart disease, diabetes, obesity and a cornucopia of allergies, all linked to the sedentary consumer culture of the developed world. Our comforts are killing us.
The prominent Canadian physician William Osler, whom we met in Chapter 5, noted in 1892 that coronary heart disease was ‘relatively rare’.438 The concept of a heart attack was unknown, the phrase first being used in the early twentieth century. By the 1940s, a study conducted in Framingham, Massachusetts, found that heart disease was linked to smoking, lack of exercise, diets rich in saturated fats and or salt, heavy alcohol consumption, stress, obesity, type 2 diabetes, high blood pressure and high cholesterol levels.439 By the end of the century, cardiovascular disease (heart disease accompanied by a stroke) was the leading cause of death worldwide.440
Many of these problems had, of course, been known in earlier times. The effects of obesity and heavy drinking were certainly known in eighteenth century Britain, as was the danger of stress: After performing an autopsy on a person who had died in a fit of anger, Scottish surgeon John Hunter (1728–93), who knew Edward Jenner, commented, ‘My life is in the hands of any rascal who chooses to annoy me.’ Hunter’s words proved prophetic: he died of a probable ruptured aortic aneurysm after having an explosive argument with a colleague at St George’s Hospital, London.441 Obesity was clearly a problem, too, as Mary Dobson notes: ‘It was frequently noted that “gross” individuals of “corpulent living, ruddy complexion, hard drinking and overindulgence” ran a high risk of disease and death, as did those who had “a want of fresh fruit and greens and the disadvantages of a low diet”.442
Doctors themselves could be just as guilty of these errant lifestyles as their patients. George Cheyne (1671–1743), spent so much time eating and drinking with his patients – who included the writers John Gay, Alexander Pope and Samuel Richardson – that, at one time, he weighed 32 stone. Cheyne’s servant walked behind him with a stool so that he could rest frequently, as he was ‘excessively fat, short-breath’d, lethargic and listless’.443 Cheyne eventually converted to vegetarianism, took exercise and fresh air, and cut down on visits to the tavern. His weight went down, and his health improved dramatically. Health advice manuals in the eighteenth and nineteenth centuries followed Cheyne’s example in recommending a good diet, lots of exercise, moderate alcohol consumption, and a balanced diet.
As Mary Dobson notes, ‘there were few specific recognizable clinical descriptions of heart disease prior to the twentieth century’.444 Diagnoses that are possibly heart-related can be gleaned from journals, mortality records, doctors’ case notes, diaries, letters and newspapers. The Gentleman’s Magazine ran a story in 1796 about a servant girl who had dropped dead while reading a letter from her beau, a fellow servant. It transpired he had run off and married someone else; the girl was said to have died of a ‘broken heart’. Other possible heart-related demises were said to be from the deceased being ‘sad’, ‘weak’, ‘infirm’, or suffering from an ‘oppression of the spirits’, a ‘pining sickness’ or an ‘iliac passion’. Some died ‘suddenly’ or ‘untimely’, while others were ‘planet-struck’, inflicted by the ‘visitation of God’, or ‘the work of the Devil’. Some died because they were ‘worn out’, ‘frenzied’, ‘distracted’ and ‘short of breath’ or declined through ‘exhaustion’, ‘grief’ or ‘old age’. ‘Decay’ or being ‘bedridden’ were often cited as causes of death in the elderly. As Mary Dobson remarks, ‘How many such sudden or slow deaths were related to heart disease is impossible to tell.’445
One of the first descriptions of what we can now say was heart disease came from English physician William Heberden (1710–1801). In 1768, he coined the term ‘angina pectoris’ – a term related to chest pains, ‘a most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or continue’.446 What constituted heart disease continued to be refined by nineteenthcentury authorities like August Hirsch, who saw heart problems as mainly causing diseases in other parts of the body. By the early twentieth century, actual irregularities, such as a heart murmur, were automatically seen as evidence of heart disease. During the First World War, a condition known as ‘Soldier’s Heart’ was common. Its symptoms of ‘breathlessness, fatigue, and a feeling of impending doom’447 were treated with extended stays in hospital, until the ailment became one of the most common causes of military discharge. After the authorities realised that keeping so many soldiers in hospital because of suspected heart conditions was costing Britain a huge amount of money, as well as weakening her militarily and putting a huge strain on hospitals, ‘Soldier’s Heart’ was re-diagnosed as ‘Effort Syndrome’. This new, less serious condition, was to be treated with a regimen of exercise, freeing up much-needed hospital beds and saving the British war chest considerable amounts of money. ‘All of this demonstrates that some notions about what constitutes heart disease are informed by social needs.’448
Even if some instances of heart disease could be thus reassigned to lesser categories, technological developments in the early part of the twentieth century certainly aided the detection of genuine heart problems. The invention of the polygraph and the electrocardiograph before the First World War helped doctors monitor heart disturbances and the pulse with better clarity than the stethoscope. By the time of the Framingham study in 1948, therefore, doctors had a pretty good idea of what heart disease was, and what was likely to be causing it.
Likewise, type 1 diabetes was rare until the second half of the twentieth century. Type 2 diabetes has become ‘predominantly a disease of older and fatter people and has become increasingly common as a result of increased life expectancy, urbanization, lifestyle chan
ges, and population growth.’449 As Robert Tattersall notes, ‘An observer in 1900 would have been amazed by the magnitude of these figures [that, in the year 2000, an estimated 171 million people worldwide suffer from diabetes] but not by the concept that diabetes was a product of wealth, dietary change, and urbanisation. A Victorian physician had even described diabetes as ‘one of the penalties of advanced civilization.’450
Diabetes was probably known to the ancients, who recorded a disease that produced large amounts of ‘honey-tasting’ urine. Diagnosed by drinking the said honey-tasting beverage, it was treated with dietary and lifestyle changes, such as an increase in physical exercise and vegetables. Many writers noted the sweet taste of the patient’s urine, although Paracelsus, never one to mince words, ridiculed ‘pisse prophets’ who claimed they could explain disease solely through studying urine, and suggested that chemical analysis should be employed if the cause of diabetes was to be found.451 Paracelsus recognised that diabetes could be a serious disease. Thomas Willis (1621–75) wrote in Diabetes or the Pissing Evil that the disease was rare among the ancients, and that the urine was ‘exceedingly sweet’ or ‘wonderfully sweet like sugar or honey’ but did not consider this to be because there was sugar in it.452 Matthew Dobson (1735–84) disagreed with Willis, believing that the sweetness came from sugar. In 1772 he evaporated two quarts of urine from a patient who was passing 28 pints (15 litres) of urine a day. The white residue that was left could not ‘by the taste be distinguished from sugar’.453
Progress was made by William Cullen (1710–90), who identified two kinds of the disease: diabetes mellitus and diabetes insipidus. Army physician John Rollo (d.1809), who studied under Cullen, tried to eliminate the production of sugar. He thought it was formed in the stomach from vegetables, and treated patients with a meat diet. Although he was wrong, as Tattersall notes, it was at least ‘an attempt to treat diabetes rationally by preventing the formation of sugar.’454 In 1815, the sugar was identified as glucose.
John Camplin, a doctor, wrote what is possibly the only autobiographical account of suffering from the disease in 1858. He noted the first symptoms in 1844, when colleagues predicted that treatment would be ‘smoothing my path to the grave’. Camplin was initially advised to eat fat meat and eggs, but this produced ‘great biliary derangement’. He was later advised to add fish to his diet, and also took to eating bran cakes ‘by no means a pleasant composition but one which acted powerfully on the bowels.’ Camplin survived his ordeal with diabetes and his doctor’s prescriptions; indeed, his book is entitled On Diabetes and its Successful Treatment.455
Dobson and Cullen had both believed that glucose was formed in the stomach. Josef von Mering (1849–1908) and Oskar Minkowski (1858–1931) discovered that it was in fact the pancreas that played the crucial role. In experiments in 1889, they removed dogs’ pancreases and found that the animals developed all the signs of diabetes; the animals answered calls of nature on the laboratory floor. In 1910, the English physiologist Sir Edward Albert Sharpey-Schafer (1850–1935) proposed the lack of a single chemical normally produced by the pancreas as the cause of diabetes. He dubbed it insulin, after the Latin word for island, a reference to the insulin-producing regions of the pancreas, the islets of Langerhans. It wasn’t until 1921 that an effective treatment for diabetes was developed by Frederick Banting and Charles Best at the University of Toronto, who discovered a method for extracting insulin from the islets of Langerhans. The discovery led to a Nobel for Banting but, in another controversy, not for Best. (Banting did at least share his prize money with him.) Shortly afterwards, the Canadian pharmaceutical firm Eli Lilly began to produce insulin for general practice.
It was a well-timed discovery, as what was probably the first reference to an epidemic of diabetes came in 1921 from American doctor Elliott Joslin (1869–1962), who became one of the first modern authorities on diabetes. He noted that six of out seven people in adjoining houses to his own in his hometown of Oxford, Massachusetts, had died of diabetes. ‘He pointed out that, had they died of cholera, the public health authorities would be round like a shot. As it was diabetes, nobody was particularly bothered.’456 Joslin established that the main risk factor in developing diabetes was being overweight, and the principal reason for an increasingly heavy population was that it was doing less manual work. Mechanisation, wrote Joslin, ‘has made industrial workers mere tenders of machines, has lightened the burden of farm workers, transferred large numbers into clerical and sales jobs, reduced hours of labour. The amount of energy expended in work, therefore, has been drastically cut down for the majority of the working population.’457 The problem with weight was backed up by a contributor to the British Medical Journal in 1932 who wrote: ‘should the national overweight continue to grow unchecked, the mortality from the degenerative nonbacterial diseases will diminish the average expectation of life.’458
Such sedentary habits were not solely confined to factory workers who were being replaced by machines. The English physician Robert Saundby noted in 1897 that ‘diabetes is undoubtedly rare among people who lead a laborious [manual labour] life in the open air, while it prevails chiefly with those who spend most of their time in sedentary indoor occupations… there is no doubt that diabetes must be regarded as one of the penalties of advanced civilisation.’459 As Robert Tattersall points out, diabetes was proving to be a dashed nuisance to members of the English aristocracy in India. ‘Much of the evidence that diabetes was a disease of the rich came from India. At a meeting on tropical diabetes in 1907, it was said that “what gout is to the nobility of England, diabetes is to the aristocracy of India” and “exercise, as a rule, is disliked by the gentleman class of Bengal after a certain age.”’460 It seems parts of the Raj were being run by men who were increasingly rotund due to a diet rich in starches and sugars, topped off by a complete lack of unbecoming exercise. Gentlemen’s subalterns could also fall victim to diabetes, such as one ‘Bengali babu’ (a clerk who could read and write English), ‘whose girth had a great tendency to increase in direct proportion to any increment in his pay.’461 In contrast, Hindu widows, who lived ascetic lives in comparison to their white ‘superiors’, were never known to get diabetes.
Bound up with both heart disease and diabetes is the phenomenon of an increasingly heavy population. ‘Obesity is not itself a disease,’ Sander L Gilman notes, ‘but rather a phenomenological category that reflects the visible manifestation of body size, which potentially can have multiple… causes.’462 Being overweight has long been synonymous with ill health, although the boundaries between the two constantly shift. Obesity doesn’t meet Koch’s postulates, as Gilman comments. ‘No one dies from obesity. One dies from the pathologies that may result from extreme overweight. It may lead to diabetes, which may lead to vascular disease.’463
Body weight (and shape and size) were important to the ancients, and ‘control of the body and its weight was an intrinsic part of religious belief. The ancient Greeks saw food as part of a complex web that connected human beings and the gods through the humours.’ Hippocrates and Galen discussed obesity, seeing it, unsurprisingly, as an imbalance of the humours. Of course, seeing the body in an ideal state, with perfect health, was more Platonic form than reality. Despite being overweight himself, the philosopher Thomas Aquinas (1225–1274) eloquently railed against overindulgence, proclaiming, ‘Let us not give our minds to delights, but to what is the end of delights. Here on earth it is excrement and obesity, hereafter it is fire and the worm.’ But when he entered the hereafter suddenly at the age of 49, his weight was such that, ‘fat as he was, the monks were unable to carry his body down the stairs.’464
Obesity has now become such a problem that the World Health Organization coined the word ‘globesity’ in 2001 to reflect what is now an international problem. As with the Victorian idea that diabetes is one of the ‘penalties of advanced civilisation’, so with obesity; but the civilisation is decidedly of the corporate-consumer-fast-food-instant-gratification kind.
As Gilman comments, ‘Obesity is dangerous to society as well as to the individual because it is now globalized: in complex ways obesity is now (as smoking was) a sign of the deleterious effect of the modern (read: the American) influence on the body.’465
As civilisation advanced through a combination of mechanisation, overindulgence and sloth, cancer likewise saw an upsurge in the twentieth century. Although ‘canker’ had been in the English language since probably the fourteenth century,466 early cases are mainly identifiable through the mention of ‘cankers’ or tumours. One early example is the story told about Raymond Lully (1232–1315), the Majorcan scholar, alchemist and crusade apologist. He had fallen in love with a beautiful young woman by the name of Ambrosia de Castello, but she continually refused his advances. Exasperated by Lully’s persistence, she revealed the reason that she could not return his love: she bared her breast, and Lully could see that it was eaten away by a tumour. (As to what happened next, accounts differ: in one version, Lully realised the folly of carnal desire and pledged to devote his life to serving Christ; in other accounts, Lully gallantly travelled to Mauritania to seek out the alchemist Geber, who was said to possess a cure for cancer.)467