Reopen the book - bacteria are back

I graduated in medicine in the early 1960s. What progress healthcare has made since. The notion of doing a coronary artery bypass on people in their 80s - such as Denis Thatcher - or giving metal hip joints to those in their 90s - such as the late queen mother - would have been greeted with incredulity then. Kidney transplants? Curing Hodgkin's disease? Pure science fiction.

Robert Desowitz's book is also about healthcare. But it is not about these successes. His depressing account is about failure, not just at the level of the individual patient, but those affecting whole populations, even continents. It is about failure in the systems that are supposedly assisting those trying to solve some of the great health problems, the major killers: diseases such as malaria, still up there with its old ally, tuberculosis, and its new companion, HIV, as the leading transmissible causes of premature death.

Desowitz does not just describe today's problems. He delves into history to find causes. One of the problems that lurks throughout his story is the decline of public health. Not so much, as he puts it, in the numbers of people "concerned with the cosmic issues of public-health policy" but in the numbers of those who deal with "the nitty-gritty of communicable diseases that once was so prominent in laboratories and classrooms".

Desowitz says that in the US, with some exceptions, "over the past several decades, teaching and research on infectious diseases has declined at our schools of public health". It has been the same in the UK. By and large, most public health professionals regard communicable diseases with disdain.

They are deeply unfashionable as objects for study. Cancer is the subject that grips the imagination of epidemiologists. Health economics is where the money is. Curriculum "reform" in medical schools has swept away subjects such as bacteriology. Most students no longer handle bacteria and viruses in practical classes as part of their scientific education. In our touchy-feely age, they spend more time studying ethics or honing their communication skills with actors or through two-way mirrors.

Why is this so? Return again to the 1960s. The famous statement by a US surgeon-general, "It is time to close the books on infectious diseases", epitomised the optimism of that decade. Antibiotics and vaccines were perceived to be so effective that minds should be bent to other problems.

But we all know now that bacteria fought back.Desowitz focuses on malaria to show that difficulties with the drug approach are not restricted to antibiotics and vaccines. Anti-malarials select for the emergence of drug-resistant parasites no less effectively than antibiotics do with bacteria. However, he reserves most of his opprobrium for malaria vaccinologists and the vast sums of money being spent on searches for an anti-malaria vaccine: "It is just as reasonable to believe that there never will be one as it is to believe that it is a done deal only awaiting the inevitable breakthrough. Seventy years of unrewarding malaria vaccine research doesn't call for abandoning the search, but it certainly calls for a hard look at what is being devoted to it." To use public-health jargon, Desowitz worries mightily about the "opportunity costs" of the vaccine approach. He thinks it would be better if much of the money was spent on improving anti-malaria strategies known to work. "Some of the brightest malaria researchers could be weaned from the vaccine and made to think about dealing with malaria in the untidy world we live and die in."

The 1960s were not only a time of unjustified optimism in our ability to control infection. The publication of Rachel Carson's Silent Spring in 1962 also left a legacy. Despite amazing improvements in life expectancy and in the quality of life, she made us all afraid. As Mary Douglas and Aaron Wildavsky said in 1982 in Risk and Culture : "What are Americans afraid of? Nothing much, really, except the food they eat, the water they drink, the air they breathe, the land they live on and the energy they use." Few would disagree with the notion that DDT is seen as one of the most important villains of the piece. Desowitz disagrees with its demonisation, and does it in style: "St Rachel, you will be happy to know that the ospreys are flourishing. But so are those other flying creatures, the anopheline mosquitoes whose unregulated breeding now brings 300 million cases of malaria each year, causing 3 million deaths, mostly of children and pregnant women." Even those who oppose Desowitz's position on DDT and put birds ahead of people will find it hard to resist his argument that public health is not just about science, disease and parasites. Politics is all pervasive and all important. The evidence he presents is compelling.

One feature of modern biomedical science that he targets for intense criticism is the new managerial requirement to "patent or perish". The legalistic profit-driven ethos that drives what he calls "the academic institutional industrial complex" outrages him, not only on the grounds that it fosters greed, but because it gets in the way of discovery. It is obvious that he belongs to the diminishing band of believers in the Mertonian norms of science: universalism, organised scepticism, communality, humility and disinterestedness. He reminds us that, at the end of the day, if the research is successful it will almost certainly mean those who stand to benefit most will be unable to afford the new vaccines or drugs because they are too poor.

Desowitz's polemic is brilliant and timely. Keeping pace with pathogens is difficult because they evolve so quickly. But his account is up to date, starting with the West Nile virus and finishing with Cryptosporidium . It informs, entertains and scares in equal measure. It is a tract for our times that can be read with profit by anyone with an interest in the current human condition.

Hugh Pennington is professor of bacteriology, University of Aberdeen.