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JUST SAY NO TO RHINO To a rational mind there are a great many things about the way in which we order our society today that appear strange. One of the most peculiar is the way in which we approach the issue of infectious diseases, in particular our attitude to how we spread them and the way that we treat other people who give us bugs. This is a thing that has come to my attention as a result of personal circumstances. Every year or two I undergo a form of chemotherapy that wipes out my adaptive immune system. This is a new treatment for Multiple Sclerosis, from which I suffer. The chemotherapy is not as terrible as it sounds - it uses a monoclonal antibody know as Campath[1] which targets the CD52 receptors on lymphocytes. So I get to keep my hair and the other half of my immunity, the non adaptive part that mostly deals with bacteria of my immunity. I do however end up with no T cells which leaves me, particularly for the first three months, much more susceptible to viral and fungal infections. The thought of getting really ill from some really boring everyday virus has a clarifying effect on the mind, to put it mildly. It leads one to rethink attitudes to infection control. In our household we become very very careful about hygiene. We don't use public transport. No buses, trains. No planes (and no airports either– there are some advantages!) and for a while, no pubs or restaurants. Home schooling for our children (they like that bit). We become quite hermit-like. The first time this happened we were too busy dealing with life to really notice the details of avoiding infection. The second time around though we started to observe just how strange the attitude of society is when confronted with infectious disease. We realised that many of the activities that we had to change were due not to me being immune compromised but more to the bizarre attitudes of people who actually were carrying disease. If a man goes into a bar and thumps another on the nose causing an injury that is 'more than trifling' (things such as scrapes and bruising are considered to be 'more than trifling') they may, in Britain, be convicted of Actual Bodily Harm or ABH. ABH carries a penalty in the Crown Courts of up to five years imprisonment. In many cases of ABH the victim will need a few days off work, say a week for the sake of argument (more serious harm is known a Grievous Bodily Harm in the UK, or GBH and generally means that you have done lasting harm to someone). Now imagine a scenario. You have a filthy cold. You have been invited out to a bar by friends though, and as a real 'trooper' you decide to go even though you feel terrible. People will even be pleased that you made the effort, it is a compliment, showing how much you enjoy their company. Whilst you are there you will probably pass on your horrible cold to half a dozen people. You have condemned each one of these people to between six to nine days of unpleasantness. They will probably have to take a number of days off work. In rare cases (and particularly if some of them are old) there will be complications that are a good deal more serious and can lead to more permanent problems, including the kind involving long term horizontal rest six feet under the ground. Your penalty for infecting these people? None. If you thumped them on the nose (horrible for a week or two) you can get five years in jail. If you infect them with a virus (horrible for a week or two) you can get, er, sympathy. The victims themselves will not even think ill of you, so bizarre is our attitude to infectious diseases. [2] If you are infected with a cold or flu virus and spend eight hours on a plane, the estimate of six subsequent infections could be absurdly low. You could have created, single handedly, several man months of misery. And I doubt that you would even think about it, never mind be troubled by it. Imagine that you had biffed all those people on the nose? Our attitudes extend to work, and move from strange to Kafkaesque. We have in fact even legislated to encourage stupid behaviour. Employers pay people when they are ill. This mad throwback to the paternalist society attracts no comment as a general rule. But think through the consequences. If you are suffering from something infectious but can still function your employer is generally pleased to see you at work. It shows 'commitment'. And since they have to pay you anyway, they want the time they paid for. Not only does this show a poor grasp of arithmetic on the part of most employers (one person with a cold infects your whole office, leading to lots of time off – why did you not send them home straight away?) but the acceptance of such behaviour by co-workers is very odd (it's less odd when you realise that they get paid anyway if they catch the bug). Due to the madness of paying people when they are ill we have the situation that one needs to produce a doctors certificate to show that one is ill. Does this not strike you as insane? Surely your employer is much more interested in making sure that you're well enough to work? They should be demanding that you produce a doctors certificate showing that you're well before they let you into the office if you look a bit ill. Such behaviours and societal attitudes are not just confined to the relatively harmless viruses. It is astonishing to note that it was only in 2001[3] that the first conviction was obtained for a person knowingly infecting another with HIV in the UK. This must have happened countless times before then. What were the previous victims told? Tough luck? Infection with HIV is still a probable death sentence. And what do you think the infectors of these victims were charged with? Attempted murder? No, they were charged with, variously, 'reckless conduct' or GBH. Sentences from two to five years of which they will probably serve half. You can get more jail time for breaking someone's leg. Even more stupidly (and unfortunately all too predictably) AIDS campaigners spoke against even these verdicts, saying that could stigmatise HIV sufferers. Now as you might imagine I have a lot of empathy with anyone suffering from a long term degenerative condition but the last time I looked HIV didn't make one grossly stupid. Of course these verdicts will stigmatise HIV sufferers. With a bit of intelligence that stigma can be attached to the vile people who knowingly carry the infection and have unprotected sex with the uninfected. That would be good stigma. If there had been more of it, perhaps these criminals might have thought twice before sentencing their victims to years of misery. There are other consequences to our strange attitudes to infection. In general, infectious diseases are getting nastier at the moment. The great medical advances of the twentieth century are spent and the bugs are fighting back. The list of increasingly scary things you can catch from other people is growing. Everyone is waiting for the next 1918 flu. MRSA is with us in the community. The scares so far have been just that, scares. SARS and Avian Flu have so far not become seriously infective in humans. But one day they will. And some bozo who thinks that it's OK to get on a plane feeling lousy will kill millions rather than just ruin a dozen peoples week. That man you saw leave the bathroom without washing his hands? The next time he shakes hands he may well give somebody something really nasty that no amount of antibiotics will cure. There may well come a day when our lax attitudes to passing on infection result in our inability to contain a serious pandemic simply because transmission is too fast. It is interesting to speculate as to why we have developed these attitudes. It is tempting to ascribe our lackadaisical attitude to ignorance. However, even before a proper understanding of microbes people knew that certain diseases were 'catching'. It seems more likely that the advances in medicine in the twentieth century are to blame. It has been rare for people, particularly initially healthy people, to suffer permanent injury or death from infectious disease in the last fifty years. It took a fairly severe incident in my health for me to notice how sloppy we all are. Without it I doubt I would have ever noticed. My mother in law, who grew up in Spain in the 1920's, remembers when people were sent straight to bed, both to get them out of circulation and for their own health, at the first sign of a cold or 'flu. It is a long time since that has been the case. The prevalent attitude seems to be that infection is a matter of bad luck, not something that can be caused by, and be the responsibility of, another human being. You win the 'bad lottery'. Fortunately this is not true. There are enough nasty random things that can happen to our health without adding perfectly preventable nasties to them. We could easily change our attitudes to infectious disease and as a consequence be better off all round. It would require some slightly uncomfortable adjustments in attitudes but none of these are too weird. The biggest change would be for everyone to feel that infecting someone else with anything is a truly nasty thing to do. You might say that people already do, but the evidence that they do not is all around us. The case of Andrew Speaker[4], the US lawyer with multi drug resistant TB, who went travelling around Europe when told to stay at home is a great illustration. Equipped with a probably fatal infectious disease (spread via aerosol) he went to Greece to get married against the advice and instructions of all his doctors. He went in a large metal tube full of people that recycled seventy percent of it's air. An aeroplane. I'll bet all his fellow passengers really enjoyed that thought. Even with something as merely unpleasant as the common cold, if we add up the cumulative years of degraded human life accumulated due to poor attitudes to spreading the virus the number is staggering[5]. And what for? So that we can be admired for 'soldiering on' in the face of adversity? So that our boss can give us a gold star for having 'made the effort' to come in? So that our friends think we really like them because we turn up for that beer even when we feel like death? These attitudes must change, they belong to an era when we did not travel, when diseases from Hong Kong couldn't reach London in 24 hours, when new flu viruses didn't travel across the country in days. It might sound impossible that we could change enough to make a difference but I have not had a cold for three years. It is a side effect of my increased care about catching bugs. I wash my hands more frequently, particularly after shaking hands. All my friends are careful to not to give me anything[6] as they know that I will suffer worse than they. Saying 'chemotherapy' and 'immune compromised' helps with that, but still, no colds for three years. Think of that.[7] If you feel even slightly unwell, stay at home. Take personal responsibility for keeping away from bugs. Wash your hands after shaking hands with others (the biggest vector for the common cold and flu is contact with hands followed by rubbing your eye – straight delivery into the nasal passage) Observe normal hygiene behaviours. Wash your hands after using the toilet. Wash your hands before handling food. Be nasty to those out in enclosed public places with bugs. Make them feel bad, make them go home. If you feel you might have something, don't go to work. Stay at home. 'Soldiering on' is not good, it is wrong and harmful to others. It is tempting to think that avoiding minor infections is somehow for wimps, part of the steady creeping cowardice that seems to pervade our society, but it is not. You do get to choose many of the risks you take in life. I begrudge every minute spent infected with a cold, they are minutes just gone from life. And if a great pandemic does arrive, well, I'd rather die by falling off my horse whilst charging across the open moor than in an ICU with a million tubes sticking out of me whist H5N1 breeds madly in my veins. John Lambert Dartmoor, June 2007 [1] Campath 1-H is a humanised mouse antibody. If you are interested in it you can look at; [2] My wife has sensibly pointed out to me that most people would feel that receiving a cold from someone is much preferable to receiving a punch on the nose from them. In terms of discomfort thus endured this is generally daft as they are roughly comparable. However a punch on the nose is always accompanied by the possibility of further, nastier, much more dangerous action which is why we have a strong natural (and very reasonable) aversion to it. In this instance though we are not comparing the relative risks of further injury, we are comparing what has actually happened. People also identify the aggression that accompanies the punch as being very unpleasant, but the moronic indifference that accompanies the cold is equally unpleasant, just less obvious and it's tolerance in our society is the weird behaviour that I am trying to illustrate. [3] There have now been a number of cases related to deliberate HIV infection in the UK. The first seems to be have been in Scotland; Subsequently there have been a number of cases in England, the most significant of which is probably the first conviction under the 1861 Offences Against The Person Act; Recently the first case of deliberate Gay transmission resulted in a conviction; [4] This very selfish man caused a furore at the time, which is a great sign that we are waking up to how stupid these behaviours are. There is a good article in Wikipedia; [5] There are actually quite a few estimates kicking around for this. The main study seems to be by Dr. A. Mark Fendrick, indicating a cost for the US measured in the billions of dollars annually. Here's the original Wikipedia article; [6] This is made easier for me because I run my own business. We pay sick pay when people are ill so I contribute to the overall stupidity but I am fortunate in having great staff who are responsible about their own health. We have a strong workplace policy about this – don't bring your bug to work, we don't want it. I am convinced that the overall effect is improved productivity over a whole year despite the fact that sometimes people stay at home when they just feel a little rough and could otherwise work. I have no numbers on this though, so it is just anecdotal. Interestingly, and predictably, the people with children at school are the ones who catch all the bugs now that we have pretty much eliminated workplace transmission. [7] I just know that after that moment of hubris I am now going to catch a stinker. |
