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Unity, Balance, and Power

The notion that parasites are ravaging populations -- and clearly, they are -- is hard to reconcile with the already-impressive and fast-accumulating evidence that the aftermath of eradicating parasites is ravaging other populations.
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Lincoln told us that a house divided against itself cannot long stand. In unity there is strength; in balance, power. In disunity and imbalance, therefore, the opposite -- weakness and vulnerability.

As I wrestle with opposing inspirations on the topic of our unity, balance, and power, I am a little confused about the state of our houses and their native inhabitants. I will share my confusion in the hope that doing so might prove therapeutic -- for me, at least. Assuming it does, thanks for the help!

Yesterday morning, I spoke at a plenary session of the Council of State and Territorial Epidemiologists annual meeting in Pasadena, Calif. I shared the session podium with two experts in very different fields, one of whom is a former Yale colleague and now dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston, Dr. Peter Hotez.

Dr. Hotez' work focuses on what he calls neglected diseases. These are infectious disease scourges, mostly parasites, affecting the 1 billion or so people on the planet still prone to starvation while the rest of us succumb to obesity. This is the population barely hanging on to the bottom stave of the socioeconomic barrel.

Dr. Hotez' talk, complete with a video showing such things as advanced elephantiasis (technically, lymphatic filariasis), was extremely compelling. His work is vitally important, and making a huge difference for a huge but underserved populations, by facilitating the widespread use of antiparasitic drugs in areas of greatest need around the globe. So, I trust you see why I was inspired. But confused?

Well, yes. Because I had already started this column before ever coming to Pasadena, inspired by the book I am now finishing, An Epidemic of Absence, by Moises Velaszquez-Manoff. Velaszquez-Manoff convinces me that much of the modern burden of autoimmune and inflammation-related disease in developed and developing countries owes something, and perhaps much, to the wholesale eradication of organisms once resident within us. This is provocative stuff for me, given the prevalence of such diseases in my clinical practice in Connecticut, and the frequency with which these conditions -- think MS, lupus, inflammatory bowel disease -- resist conventional therapies.

We have long known that resident bacteria outnumber our own cells by an order of magnitude. Velasquez-Manoff explores much further reaches of our inner menagerie, showing associations between the eradication of parasites and microbes and the onset of specific modern ills in distinct populations. Exposure to malaria is clearly not a good thing, but it may -- for some of us at least -- prevent multiple sclerosis. Intestinal worms may have the potential to prevent, and perhaps treat, inflammatory bowel disease. The bacterium Helicobacter pylori may reduce the risk of certain cancers, even if increasing the risk of others. And in this and many other cases, risks and benefits may vary with the timing and circumstances of exposure.

Velaszquez-Manoff's account, relevant to everything from rheumatoid arthritis to obesity, is logical, beautifully reasoned, clearly articulated, and meticulously researched. Dr. Hotez is better qualified than I to find subtle flaws in the case, and this morning I encouraged him to read the book. I hope he does so, and look forward to his impressions.

In the interim, I am contemplating an adaptation of my clinic to accommodate the insights and opportunities with which An Epidemic of Absence is replete. I believe that therapeutic use of organisms once thought to be parasitic, and now found to be symbiotic, is apt to transform modern medicine. Some who blazed the trails of insight in this area may join the ranks of Nobel laureates.

I confess, though, that as a practicing physician reading this book, my abiding fascination was plagued by frustrations. We don't yet know what organisms are best for whom, when, or in what doses and combinations. Much work remains.

And these frustrations are acutely compounded by Dr. Hotez' impassioned reality check yesterday morning. There may, indeed, be an epidemic of absence for those of us in the privileged majority, but Dr. Hotez devotes his considerable expertise to the plight of the 1 billion person minority still mired in epidemics of the old-fashioned kind. It's a whole lot easier to contemplate the downside to killing intestinal worms when intestinal worms aren't busy killing you.

The notion that parasites are ravaging populations -- and clearly, they are -- is hard to reconcile with the already impressive and fast-accumulating evidence that the aftermath of eradicating parasites is ravaging other populations. If Dr. Hotez is right, must the argument of Velaszquez-Manoff be wrong? If Velaszquez-Manoff's argument is valid, are Dr. Hotez and colleagues doing inadvertent harm along with obvious good?

I am confused, because I find both arguments compelling and very persuasive. We must treat the masses whose lives are being ruined by parasites in the present. But I do think the co-evolution of our immune systems with the diverse members of our inner menagerie has implications for what may happen tomorrow if we continue to act as if the only good microbe is a dead microbe, the only good worm a dead worm.

Unity, if you pause to reflect, is a fascinating word. We use it in such context as "in unity, there is strength," referring specifically to the cohesiveness of a group. But unity derives directly from the root of the word for "one." It is as much about one as it is about many, and vice versa. It is about one from many, and many acting as one. So, too, the word "universal," which is when everyone rallies around the same idea.

With regard to health, unity -- in all of its connotations -- is proving to be a concept of universal relevance and profound importance. In my area, chronic disease, I have long argued that many of the best defenses of the human body reside with the body politic. My lab conducts community-based participatory research, which emphasizes the cooperation implied by, and the unity at the heart of, community.

In health policy, we know that disparity is an even greater goad to bad outcomes than poverty itself. It's not so much struggle, as disunity, that makes people feel helpless, and hopeless, and consequently, disease-prone. And more and more, courtesy of the work of many cited in An Epidemic of Absence, we are learning how dependent we are on a unity of function among the many tenants within our own skin.

Community is based in biology. We are social creatures, within and without. That's biology, not ideology.

But just as bad actors in a group of people can do terrible harm and must be dealt with accordingly, so too the pathogenic members of the zoo within. The great challenge before us now -- inspiring, and potentially confusing for the foreseeable future -- is to deal harshly with the true enemies within, while allowing for the potential presence of friends.

I believe Velaszquez-Manoff is right, and it is past time to commune with the unity on which our health depends. It turns out that while unity is intrinsic to community, the converse may be just as true. We unbalance populations both without, and within, at our peril. But I am certain that Dr. Hotez is right, and the parasites ruining lives must be hunted down.

We are aiming at the power of a balance we are just beginning to understand, a unity we have just begun to recognize. Much, therefore, will depend on the balanced application of our powers, and the wisdom within which we house them.


Dr. David L. Katz;

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