The Glamour of Microbiology

Microbiology is one of those subjects which cause a double eyebrow-raise at dinner parties. "Oh! that must be interesting" is the usual reply, the emphasis revealing that there really isn't a follow-up question available for this area. No, microbiology is no Neurosurgery or Cardiology. No eighteen holes at the week-end for those who gaze down microscopes at Gram stains. But it can be fun nonetheless.
Nha Trang is a small city on the coast of South Central Vietnam. If you stroll down Tran Phu along the beach, you eventually come to the Institut Pasteur, a site of great importance in the history of infectious diseases. In 1891, a young Frenchman by the name of Alexandre Yersin set foot in Nha Trang and instantly fell in love with the place. Flanked to the east by the dark, turquoise waters of the South China Sea, and to the west by steep, green mountains, it isn't difficult to see the attraction. A promising scientist, Yersin had left Europe and the shadow of a certain Louis Pasteur in search of adventure. He joined the French Navy as a doctor and his first mission took him to Indochina.
Realising the excellent opportunity for microbiological research which the Far East offered, Yersin set up a modest laboratory in Nha Trang. Within a few months, an epidemic of bubonic plague hit Hong-Kong and Yersin decided to join the race to discover the organism responsible for the Black Death. The germ theory of disease was still in its infancy: what a coup it would be to unmask a disease which had claimed hundreds of millions of lives for over a thousand years! While several scientists looked for the bacteria in patients' blood, Yersin instinctively assumed that he would find it in the buboes, those swollen, necrotic lymph glands which give the disease its name. He struck gold: in 1893 he identified and described the microbe responsible, which has subsequently been named Yersinia pestis in his honour.
Back in Nha Trang, in the newly-founded Institut Pasteur, he set about creating a serum to cure the disease in the same way that Pasteur had done for rabies. He was successful again and his discoveries were able to immediately save thousands of lives. Not one to rest on his laurels, Yersin turned his attention to agriculture, developing strains of Rubber and Cinchona tree which would thrive in Vietnam, providing both rubber and quinine. He founded the Ecole de Médecine in Hanoi and also went on map-writing missions, discovering a route south to the Mekong delta and west to the mountain resort of Da Lat.
Yersin made Vietnam his home and never left. At his death in 1943, thousands of Vietnamese attended his funeral, and a Buddhist shrine and pagoda were erected by his tomb near Nha Trang. Still today, locals come to pay homage to a man who they consider gave his life and work to his adopted land.

Microbiology: no golfing week-ends, but potentially a prolific career in the sun and the eternal gratitude of an entire nation.

The Malaria Ward

No flip-flops, shorts or vests; white coats are compulsory. Those were the rules explained to me before my 1st ward round on the Malaria ward. A short walk in the shade of some palm trees takes us from the OUCRU (Oxford University Clinical Research Unit) to the ward. The last 25 metres are not sheltered from the sun, and it makes us pick up the pace. The shade of the malaria ward is most welcome, but the heat is still there. There's a small oasis of cool in the air-conditionned doctors' office, where we wait for everyone to assemble. To get there, we have to single-file past two beds which lie in the corridor, each one carrying a very tired-looking patient.
The ward's name is misleading: the vast majority of the patients on this ward (13 in total today) don't have malaria. The name is historical, as this was once the ward where all malaria cases were treated. There was a time when malaria was a great burden for Vietnam, as it still is in much of South-East Asia. In 1991, there were nearly 2 million cases and more than 4,500 deaths from malaria in this country. Since then, thanks to a massive commitment from the Vietnamese Government, and significant financial assistance from the World Bank, Vietnam has succeeded in almost eradicating the disease. By 2003, cases were down to 37,416 and there were only 50 deaths.
Based on this morning's round, a more suitable name would be the Meningitis ward. Bacterial, TB, viral; even eosinophilic, a new one for me. The Vietnamese doctors summarise the case in English, for the benefit of the 2 or 3 members of the round who don't speak Vietnamese. I listen carefully, trying to block out the noise of the large fans on the ceiling. Ceftriaxone, vancomycin, ampicillin - some rebel patients still refuse to get better. It's difficult when a CT scan implies a drive through the city in an ambulance; in a city like Saigon, the drive itself could prove more dangerous than the meningitis....
Having seen a single case of malaria, we leave the ward and enter the ICU. In a side-room, a young man lies spread-eagle on a bed, the haemofiltration machine doing its best to rid his blood of the parasites within it. "This patient spent many years in a malaria-endemic region of Vietnam", we are told. Those tend to be the more rural and forested parts of the country. "His parasitaemia level is nearly 10%". That's very high; I try to remember what the management for severe malaria is. "We think he has brain death".

And there it is, malaria's latest victim. Perhaps the name of the ward serves as a useful reminder.


Barat, LM. "Four malaria success stories: how malaria burden was successfully reduced in Brazil, Eritrea, India, and Vietnam." Am J Trop Med Hyg (2006); 74(1):12-6.

The end of infectious diseases?

In 1965, Dr William Stewart was appointed US Surgeon General. These were challenging times in Public Health. A year earlier, Stewart's wonderfully-named predecessor, Luther Leonidas Terry, had overseen the publication of a report on the links between smoking and lung cancer. This in turn followed a landmark report published in the UK in 1962, which stated clearly that smoking was a cause of lung cancer and bronchitis. These were the first steps in a long struggle between public health doctors and the tobacco industry, a fight which goes on today despite the advantage having clearly shifted from the latter to the former camp.
In 1967, William Stewart, realising that chronic diseases such as cancer, cardiovascular disease and diabetes would soon take over as the leading causes of mortality, infamously stated that it was "time to close the book on infectious disease" (well, maybe he didn't; some claim he was misquoted - perhaps he mis-spoke?). To be fair to him, antibiotics had recently revolutionised the treatment of communicable diseases, and immunisation programs were gathering pace in most developed countries. Polio was on the way out. Polio! There was obviously cause for optimism.
Well, the 1960s weren't just tough in the corridors of the Center for Disease Control and Prevention. The magnitude of the conflict in Vietnam was becoming plain for all to see - Stewart was actually under a lot of pressure to reduce public health expenditure because of the cost of the war. Yet Vietnam also offered good evidence that the book of infectious diseases was nowhere near its final chapter. In 1965, Cho Quan hospital in Saigon was building a new contagious diseases ward and a new operating room for leprosy patients. The hospital was already over 100 years old by then, and has kept on growing since - in 1979, it became the first hospital in Vietnam specialising in infectious diseases. Today it is called the Centre for Tropical Diseases, and it lies just outside the centre of Ho Chi Minh City.
A brief meeting this morning with Dr Chinh, Director of the hospital, reminds me that while infectious diseases seem quite small-print when you are in Oxford, they are very much the bread and butter of medicine in many parts of the world. At any one time there are at least 10 patients in the hospital suffering from tetanus. Then there's the TB, the dengue, the HIV. Oh, and malaria's thinking of making a comeback in Vietnam.
They're nowhere near extinction. Infectious diseases are here to stay and may well become an even greater problem as climate change exerts its effects. I expect the next few weeks will help drive the point home for me. If there are any interesting stories along the way (and I'm sure there will be), I'll let you know.