04.16.14 9:45 AM ET
Following Tuberculosis From Death Sentence to Cure
In his new book, The Remedy, Thomas Goetz explores the history of tuberculosis—once a death sentence that claimed 2 percent of U.S. and U.K. populations each year. The Remedy follows the paths of two key players, both physicians—Robert Koch and Arthur Conan Doyle (yes, the Sherlock Holmes Conan Doyle)—and the quest for a cure.
Koch, a spirited country doctor, was a leader in early microbiology and the modern scientific method, and discovered the TB/germ connection. His “cure,” however, wasn’t a cure at all, and often did more harm than good. Conan Doyle, who witnessed TB’s destruction in hospitals, remained skeptical of Koch’s remedy (but was completely inspired by his scientific method). Conan Doyle eventually left medicine and created Sherlock Holmes, a character who brought science to the masses.
Through narrative and mystery, The Remedy traces the seeds of modern science and medicine.
For people who aren’t familiar with your background, can you give a quick overview?
Sure. I was at Wired for about a dozen years—2001-2012. [For] the last half of that, I served as executive editor. Along the way, for fun (!), I got my master of public health degree at Berkeley, with a focus on epidemiology.
And you wrote your first book then—The Decision Tree.
Right. Out of the MPH program I wrote The Decision Tree, which was an argument for how technology and data could help people make better decisions about their health. It stemmed from the observation that even though both technology and public health share the goal of scale, neither discipline had gotten very far in exploring the combination. That book came out in 2010, and thankfully there’s been a lot of enthusiasm for the potential of technology to improve healthcare, often from the consumer’s point of view.
So it was sort of an “idea book,” and inspired by my pal Steven Johnson, who toggles from idea book to narrative non-fiction quite well, I thought the next book should be a tale. A narrative.
I had read about this odd encounter between Robert Koch and Arthur Conan Doyle in the New England Journal of Medicine, and thought it might make a great story. It was a great little essay in 2005 that my father sent me. And I thought, “That has got to be a book.” Of course once you think that, you think that somebody else must also be thinking the same thing. So I was totally paranoid that there was some other writer out there who had caught wind of this same historical footnote. So after The Decision Tree came out, I thought I just had to tackle this.
The fun part was realizing that this one-page essay actually had the makings of a full book, because these two characters were part of a much larger story about how scientific discoveries evolve into social change. But that process is neither inevitable nor easy—it takes collaboration, even unintentional collaboration, as in the case of Koch and Conan Doyle.
What was the research and writing process like? How long did it take from start to publish?
I started in 2011, and handed in the MS last spring—so about 2 years of work. But the amazing thing is this book would’ve taken me twice as long, or more, if not for two amazing tech products: Google Books and Twitter.
Twitter is an unexpected answer. How so?
Google Books because the book revolves around the last quarter of the 19th century, when there happened to be a boom in popular publishing—an explosion especially in scientific publications and popular scientific publications. And thankfully, it’s all out of copyright and in the public domain. So it’s this sweet spot—that means there’s a lot of material on Google Books.
Twitter because sometimes that material was in German, and not just German, but written with what’s called “black letters”—this intense gothic typeface that’s hard for German speakers to read, and hard for Google translate to read. I had some letters from Koch that were a goldmine for the book—his letters from the front during the Franco-Prussian War. But I couldn’t make them out at all. So I went on Twitter and posted a picture of the page and said, ‘Anybody out there who can read this for me?’ And thank god there was: Marco Kalz, a professor of technology in the Netherlands. For payback, I got him an invitation to Google Glass.
You write something in the beginning of the book: ‘If there’s one caution to this tale, it’s this: Avoid the temptation to read the story, and the science within it, as the inevitable march of progress, a predetermined direction for human history. Especially where scientific investigations are concerned, it’s a fallacy to treat history as an unstoppable trajectory away from ignorance and toward insight.’ Can you explain that more?
Well, it’s obvious in some regard: that history isn’t predetermined. But I thought it was worth underscoring because when it comes to science, we assume all previous discoveries were preordained. But those discoveries don’t just happen—they are the very real product of men and women and struggle and failure and all sorts of human foibles. The stories of discovery are so rote, though, that we forget that they took incredibly hard work.
Part of this story, in particular, is the way that credit and acknowledgement and fame were so essential to the story—you have people like the French scientist [Jean Antoine] Villemin who kind of discovered the TB bacteria, but nobody believed him, so he doesn’t get credit. And then you have Koch, who was so diligent that nobody could reasonably doubt him.
Really, the story is an example of how it is harder and harder to convince people to care about discovery. It starts with a scientist’s peers—they are the first audience. Then the second hoop is the profession, then industry, then finally society at large. I call it (forgive the lofty phrase) the arc of innovation—and many, many discoveries fall short along that arc.
By the time it gets to society, most don’t realize it had to go through all those hoops.
Right—just like germs. We just assume that germs exist—the 5-second rule and everything. We think it is natural to fear germs. But that is entirely learned behavior. In fact, it would seem insane to someone in the early 19th century to fear ‘germs.’
And that once there were ‘germ deniers’!
Exactly. Think of the scale of that shift in social consciousness. How massive a shift that is! [It] makes you think what we believe to be true now, that will end up being totally disproven.
You write in the books that ship technology—boats sailing the ocean—was what got people to care about science. ‘Suddenly, science mattered; it was something people wanted to know about, to keep pace with, and to understand.’ Do you think that feeling exists today?
In fact, I think this is so ingrained now that in many ways, we assume too much of science. We assume that medical science has all the answers, when there is massive uncertainty in what we do and don’t know.
So we take it for granted in many ways, and so we are jaded by all the great discoveries. And when science comes along that really should shake us to our core, like climate change, we just don’t grasp what it’s telling us. In some ways, I think, we expect that science will take care of that problem, too. I know I fall into that sometimes. But again, it goes back to the fact that somebody out there—some scientist—has to actually be working on the problem and making progress. And that is not guaranteed.
You say too, that people often think every disease can be ‘cured’—and if there isn’t a cure now, there will be. Is this type of thinking dangerous?
I totally understand why we think that way. Science has worked its way to be able to at least treat many diseases. But we have unreasonable expectations, especially when driven by the emotions of ourselves or a family member in a very real position of needing a cure. It’s actually something we’re working on a lot at my startup, Iodine—how do we communicate the uncertainty of any given treatment to people in a way that helps them navigate information?
It’s a very slippery problem, and one that physicians deal with every day. It goes right to the messy nexus of human behavior and psychology and the limitations of science and the mystery of molecular medicine. It’s not something we’re gonna figure out anytime soon.
I was fascinated and horrified by the hospital scenes in the book, when Conan Doyle is visiting people treated with tuberculin. The image of people with ‘twisted joints, rotting limbs, skin ulcers’ really stuck. And yet, the drug still took off like crazy. So were people just misinformed? Or blinded by hope of a cure?
Oh yeah, [that is] one of my favorite parts of the story. To me it really demonstrated how chaotic the experimental process was back then. In fact, until the ’40s and ’50s, it didn’t get much better. There was just no uniform process for conducting an experiment, let alone human trials.
I think the enthusiasm for a cure was so strong that it became a spectacle and an event to have access to this thing that had already been hailed as a remedy. Nobody conceived of a thing like the placebo effect or researcher bias —none of these notions had been worked out yet.
Which is where the horror comes in—dosing infants and the elderly, administering small doses and massive doses, all with piss-poor record keeping or consistency. It was likely the largest human experiment in history up to that point. and it was a massive disaster.
And what was the drug’s ultimate downfall?
Basically, it didn’t work. It was dead bacteria and glycerin—and it provoked an immune response, but no immunity. And Conan Doyle turned out to be exactly right in his verdict: it was useful as a diagnostic, but not at all as a treatment. I love his quote: “It is as if a man whose house was infested with rats were to remove the marks of the creatures every morning and expect in that way to get rid of them.”
So, after reading The Remedy and thinking about the state of modern medicine, should we be more skeptical? More thankful? Maybe both?
I guess I’d say both—thankful that we have left the age of rampant infectious disease, but also skeptical that the weapons we rely on now will endure.
We have basically over-calibrated in our reaction to germs—our aversion to them has created a new vulnerability. Our overuse of antibiotics has created a risk that they’ll work for maybe 100 years, at best, but that the microbes will prevail. And that’s not even getting into the microbiome, which undermines the whole idea of “germs,” and might actually inform a new conception of what we call “non-infectious” disease—it may turn out that even non-infectious disease has a significant microbial component.
Do you think antibiotic resistance is the next great public health crisis?
The next great public health crisis? I think we’ll probably have some other ones before antibiotics die out. Some emergent disease or other. But I would definitely put it on the list of top 10 concerns we aren’t dealing with.
What about Ebola (in Africa), polio (in the Middle East), and measles (in the U.S./U.K)?
Well, Ebola is horrific but doesn’t travel well. And polio isn’t on the rise so much as turning out to be very difficult to entirely eradicate, mostly because of social complications. Anti-vaccination ignorance continues to kill and injure people in communities that should have no trace of such disease. I think all of these are examples of how public health is supremely important to the culture we have created and the society we expect to live in—but we give public health too little respect, in terms of resources or policy.
Too often, we think of these things as somebody else’s problem—often poor countries—and we expect our personal liberties and judgment to outweigh the social consequences of those judgments. It’s a sticky area for a free society.
What do you hope readers will come away with after they finish The Remedy? How can we apply it to a modern perspective?
First, I hope that people just go with the story—that in this marginal episode in the lives of two historic figures, there is actually a powerful tale about the tenuous role of science in our lives. It is really a way to learn about how medicine, as we understand it, came to be.
And I think in terms of modern relevance, we are still working our way through the same sort of questions today that were at hand then. Not only things like the controversy over vaccinations or the role of germs, but also the grander challenge of how much we expect of science and technology, and how the process of turning discovery into utility is actually a very fragile process.
But mostly, I think it’s just a great story with lots of cocktail party value—did you know that spitting in public used to be considered healthy? Did you know that five times as many people died every year just 150 years ago? Did you know that the first Sherlock Holmes stories were a bust? There’s a lot of dinner table fodder in this book!