Infectious diseases from a medical and cultural-historical perspective: an interview with the physician and chemist Klaus Peter Kohse and the contemporary historian Malte Thießen.
QUESTION: Professor Kohse, the situation in West Africa seems to be calming down a little in some countries, the USA is Ebola-free again and there are no reports of infections in Europe either - can we breathe a sigh of relief?
KOHSE: Ebola is far from over in West Africa too. There are still plenty of new infections, there are still deaths and it will be a while yet. However, the likelihood of it spreading to Europe or the USA is very low.
QUESTION: And cases like that of the nurse who was infected while caring for a missionary who had been brought back to Spain...
KOHSE: These are isolated cases of such infections, which can still be counted on one hand. Just for comparison: in Germany, 3000 people were newly infected with HIV last year. 3000 - that's a different number! There are 20 million HIV patients worldwide. The Ebola cases are very tragic and also highly dangerous, but epidemiologically I don't see any danger.
QUESTION: In your opinion, to what extent does public perception do justice to the respective diseases and their dangers?
KOHSE: There is indeed an imbalance. Of course it deserves a lot of media attention when people die of Ebola in Africa and the number is increasing. No question about it. But it has to be seen in relative terms. Not only in relation to the millions of AIDS patients. Also to the millions of children who die of diarrhoea in the Third World. These are completely different figures - as tragic as this Ebola outbreak is and as difficult as it is to combat locally. Or influenza. Just normal influenza: hundreds of deaths every year - in Germany alone!
Different attention windows
and threat scenarios
QUESTION: Prof Thießen, you recently published a volume on the history of epidemics in the 20th century. How does this difference in perception come about?
THIESSEN: It is crucial and interesting to look at when a window of attention opens for epidemics - as we non-medical professionals often refer to infectious diseases in our everyday dealings. And indeed, the example of AIDS shows very well that epidemics must be linked to current fears or concepts in order to become a public issue at all. So when AIDS broke out, it immediately became a huge topic, even though in terms of numbers, for example, it didn't really play such a big role in relation to the number of normal flu deaths at the time...
KOHSE: Exactly.
THIESSEN: ... but Aids was the big issue in the 1980s because it was about sexual norms at the time, because it became a hot topic in the media as a supposed gay epidemic, and this gave the disease a social dimension. I also perceive Ebola in such a way that epidemics in Africa or Asia always play a role here when they can be linked to current discussions such as those surrounding globalisation. Even millions of cases or tens of thousands of deaths in Asia don't play a role here as long as they don't seem to be a problem for us in the West. This explains the different attention windows for epidemics.
KOHSE: Indeed. A different threat scenario is also seen. Take HIV, for example: people have become a little too careless now that a diagnosis is no longer an immediate death sentence. In this respect, the situation with Ebola is actually different because you have a high mortality rate here: At the moment, 50 to 70 per cent of those who become infected with Ebola also die from it. This creates a different potential threat, even in the West.
QUESTION: If there were to be a case of infection in Germany, how would you see our healthcare system organised?
KOHSE: We have centres of excellence in Europe and North America for the treatment of such diseases. Germany also has a few centres where such patients can be optimally treated. With all the necessary structures, including diagnostics, including therapy, all of this, and integrated into the international network of the World Health Organisation (WHO).
Epidemics do not stop at borders
-actually a banal realisation
QUESTION: Mr Thießen, your anthology certainly sees deficits in the global fight against epidemics. Are the often nationally focussed healthcare systems sufficient to meet the global challenges posed by infectious diseases?
THIESSEN: The historical development with regard to international interdependencies in the healthcare sector is also interesting. Long after 1945, disease control and prevention were still national projects. Even after the founding of the WHO, there are still conflicts, as national concepts take effect when infectious diseases break out - regardless of the standardisation of certain measures. Coordination doesn't always seem to be very clear at first, which only slowly improved from the 1990s onwards in favour of a de-nationalisation of the fight against infectious diseases. Or what do you think about this as a doctor, Mr Kohse?
KOHSE: It is primarily the task of each national healthcare system. That is the original responsibility. The state healthcare system has to ensure that there are programmes in place to diagnose and treat infectious diseases. On the other hand, with today's mobility, it is no longer possible to tackle this task alone, within a national framework - diseases do not stop at borders.
THIESSEN: And interesting from a historical perspective: that it is a long learning process before healthcare systems realise that epidemics do not stop at borders. A very banal realisation, actually. Take Aids, for example: although there was an exchange in the 1980s, national systems took effect. From a historical perspective, it is to some extent due to the Cold War that disease control became a kind of performance test in the East-West confrontation. The eradication of polio and smallpox is also ultimately a question of East versus West, who has the better system.
KOHSE: The battle of the systems.
THIESSEN: Exactly. And it was striking for us how long that continued to have an effect. Even in the 1990s, you could still see a certain block formation in the fight against epidemics.
QUESTION: From a medical point of view, why is Ebola so particularly difficult to combat and has this high lethality rate that you mentioned? Why is Ebola so deadly?
KOHSE: Ebola causes damage to the organism against which there is no repair mechanism. It causes such damage at the cellular level that organ systems literally collapse. The liver and immune system fail, later red blood cells are destroyed, blood clotting is disrupted and patients develop the haemorrhages that characterise this disease as so-called haemorrhagic fever.
The fight against epidemics as a
social and political performance test
QUESTION: Will the pathogen possibly still change, what scenarios do you expect? Tests have also been started in the search for a vaccine. When can we possibly expect an effective therapy?
KOHSE: There are various approaches, some of which seem to promise success. But will we have an Ebola therapy in a year or five years? Even those who are working on it have different levels of optimism. We must also not forget: Diseases of civilisation such as diabetes are, of course, the subject of billions in research funding to combat them. But for such a rare disease - Ebola is still a relatively rare disease - funds are not invested on a large scale, resources are limited. That's why we don't have anything yet.
QUESTION: Mr Thießen, you recently made the critical comment that the lack of an Ebola vaccine may also be due to the fact that the majority of patients are located in Africa...
THIESSEN: Of course, I don't want to create any conspiracy theories. But from a historical perspective, malaria research, for example, is heavily subsidised in Europe when it has a corresponding relevance - in terms of colonial policy or due to cases of the disease in Europe. The development of preventive measures in particular seems to be linked to the priorities of a society, to the question of which risk groups are relevant to it.
KOHSE: That's true. Of course, it is also a question of optimising the use of resources. You have to prioritise in such a way that you achieve the greatest possible benefit for the entire population of a country. And if I have a small group with a certain disease, I can't take resources away from the large majority and make them available to the small minority. It's a question of economics. And malaria is an example of how the fight against an infectious disease can drag on for decades. Malaria is also a colourful story, especially when it comes to the interplay between economic and political aspects.
THIESSEN: There is an interesting example from Italy under Mussolini. There was a major programme there, and the disease obviously played less of a role than fantasies of feasibility. Malaria is an occasion, yes, but it's about demonstrating that nature and biological processes can be controlled by state planning, so to speak.
KOHSE: That certainly comes into it again (both laugh). These are aspects that always play a role in such programmes. It's not just concern for the health of the population that drives politicians.
THIESSEN: Mussolini is perhaps a mean example. Nevertheless, it is interesting to note that combating epidemics is a social or political performance test that was also adopted in the 20th century. There were also malaria programmes in the USA, so not only fascist, but also democratic - disease control as a resource for legitimacy. That may not be the only reason, but it does play a role.
KOHSE: It's a good way to kill two birds with one stone.
A never-ending task
QUESTION: What are the main challenges in the fight against epidemics, the main problems - from a medical and cultural-historical perspective? Is it a misconception that we can fight them?
KOHSE: That is a philosophical question that can really only be answered in this way: As long as there are infectious disease pathogens, there will be infectious diseases. We will never be able to completely eliminate infectious diseases because humans are susceptible to them per se. Continuously reducing the likelihood of infection is a national and international task. And of course we are talking about programmes not only in developing countries, but also in developed countries.
QUESTION: Can you give an example?
KOHSE: Measles, for example: We need thorough vaccination programmes and sensible education of the population so that we don't bring back diseases that were thought to be long forgotten due to people refusing to be vaccinated. The fight against infectious diseases is a task that is never finished, but one that requires sustained and continuous commitment in order to reduce the risk of infection. Take Ebola, for example: this is particularly difficult in Africa because cultural aspects, such as funeral rituals, also play a major role in how people live together. You have to deal with this responsibly and sensitively, it's difficult. But that applies to developing countries as well as industrialised nations.
QUESTION: What are the biggest hurdles from a historical perspective?
THIESSEN: Of course, cultural history can only solve current problems to a limited extent...
QUESTION: ... but it is certainly possible to learn from history...
THIESSEN: ... in this respect, there is a connection to be made: a rationalisation of the discourse, an increased enlightenment, is indeed a task that historical science can perform. By looking at how we deal with epidemics, we can reflect on and problematise the way we deal with our own fears and ideas. History in particular, with its studies on international social interdependencies, can show that national concepts, in which we have been stuck for a very long time, also represent a health problem. That we as a society need to broaden our view of health risks that don't seem to affect us directly at first, but which have a very strong global connection.
QUESTION: And would you say that the necessary lessons have already been learnt from history?
THIESSEN: (smiles) I think it is difficult to draw direct lessons from history. But history as a tool for reflection can, for example, help to ensure that processes that were thought to be long gone - such as the stigmatisation of marginalised groups - do not occur again. For example, when AIDS emerged in the 1980s, this infectious disease was dealt with in a way that was partly reminiscent of the Middle Ages. The fact that we as a modern society are constantly scrutinising ourselves and creating a more rational approach to health risks - also with regard to current fears about Ebola - is something that history can provide a basis for.
KOHSE: As the saying goes: if you don't know the past, you can't shape the future.
Interview: Deike Stolz