Fighting disease

From smallpox to AIDS, how the world has battled infectious diseases

If we are to save the world from the threat of infectious diseases, we need to learn the lessons of past outbreaks.

In 2013, the World Health Organisation declared antibiotic resistance was a threat to global health security. It can seem hard to believe that in the 21st century infectious diseases remain such a profound existential risk. But this declaration highlights the ever-lingering threat of infectious diseases and our dependence on antibiotics to stave off their impact on human and animal health and industry.

It also reminds us to appreciate antibiotics as one of many advances in infectious diseases and public health during the past century, and reflect on some of the greatest, still persistent, infectious disease challenges facing us today.

Here we explore our past and present struggles with four of the most significant infectious diseases human beings have faced, some of the progress we’ve made in prevention and treatment, and possible future directions.

Infectious disease deaths. Reprinted with permission from Macmillan Publishers Ltd: Nature. Paulson T. Epidemiology: a mortal foe. Nature 2013.
Infectious disease deaths. Reprinted with permission from Macmillan Publishers Ltd: Nature. Paulson T. Epidemiology: a mortal foe. Nature 2013.


Tuberculosis or TB has been responsible for the death of more people than any other infectious disease in history; over a billion deaths in the past 200 years. Its origin is unclear, but it infects a number of other species, including cattle.

Today, about a third of the world’s population is thought to be infected with TB, in its dormant form. This means the bacteria is present but it’s controlled by the immune system, the infected person has no symptoms, and it can’t be spread to others. The bacteria will reactivate in a small proportion of people and they may develop symptoms including fever, sweats, weight loss, fatigue, cough, and haemoptysis (coughing up blood).

TB occurs in every country, including Australia, but mostly occurs in people born in countries where TB is more common, due to the reactivation of dormant TB infection. Patients with weakened immune systems due to chemotherapy, HIV or other medical illnesses are at higher risk of TB.

In 2015, there were 10.4 million new cases of TB, and 1.8 million TB-related deaths around the world?, with the vast majority of cases in developing countries. The infection and death rate have been declining internationally since the early 1900s.

Long before the availability of treatment options, improvements in sanitation, housing, and vaccination led to a reduction in the rates of TB in some countries. But antibiotics made it a curable disease; without them, up to 70% of people with active infection die from TB.

But treatment is complicated, and typically involves taking four medications for two months, then two medications for a further four months. These medications are not without side effects, and can be poorly tolerated. Unfortunately, when medications are not taken or prescribed properly, the TB bacteria can become resistant to these treatments.

In recent years, drug-resistant TB has been documented all over the world, but is much more common in people previously treated for TB, and in Russia, China and India.

Treatment of resistant TB is much more complicated, takes longer, is more prone to failure, and often uses more toxic drugs. New rapid tests can diagnose TB, and whether or not the bacteria will be resistant to our first-line drugs.

A vaccine for TB has been available for around a century, but is most effective in preventing severe TB infection in children. The vaccine’s efficacy is much less clear in adults.

Despite advances in treatment, tuberculosis continues to occur disproportionately in the developing world. Although progress is being made, ongoing and increased political and financial support is essential to ensure coordinated diagnosis, surveillance and care strategies, and universal access to these. Similarly, continued investment is needed for the development of new tools to detect and treat TB.


Smallpox was caused by the variola virus, which plagued humanity for millennia and had a lasting impact on human history. As late as the 1960s, smallpox was still endemic in Asia and Africa, with an estimated two million deaths occurring annually.

Smallpox was spread easily between people by sneezing or shared contact, leading swiftly to the characteristic disfiguring pustular lesions on the skin. The disease was severe, with about 30% of affected people dying, while the rest were left with complications associated with infection. These included a multitude of scars, blindness, infections and arthritis.

Those who survived, however, were generally protected from reinfection. Building on observations that milkmaids were protected from smallpox, Edward Jenner, an 18th century British physician, developed and popularised a technique called “vaccination” whereby he deliberately inoculated a patient with cowpox, a closely related virus the milkmaids were exposed to. This led to protection from smallpox.

While a popular origin story, alternative approaches to protection, such as inhaling dried smallpox lesions, had likely been practised in China and India for many years previously, and had already been introduced into the United Kingdom. However, inoculation with smallpox came with a risk of severe infection in a significant number of recipients, and Jenner’s safer approach was adopted for larger scale immunisation programs.

In 1980, smallpox became the first, and so far only, human infectious disease to be declared eradicated by the World Health Organisation. This came about via a coordinated international response, led by an Australian microbiologist, Frank Fenner. This involved mass-vaccination, along with public health surveillance and preventative measures, which aimed to educate communities, and identify and contain individual cases.

The last case of smallpox was reported in Somalia in 1977, with the unfortunate death of medical photographer Janet Parker in 1978 serving as a final warning of this deadly condition.

Smallpox may be gone as a disease, but the variola virus controversially remains, kept secure in laboratories in Russia and the US. Concern has emerged about the prospect of smallpox as a weapon of bioterrorism. The impact of such an event could be devastating, given people are no longer routinely immunised against smallpox.


In the early 1980s, a small number of gay men in the United States started presenting with unusual infections, previously only seen in people with severe immune deficiencies. Over the subsequent years, the human immunodeficiency virus or HIV was discovered, and its global burden was recognised.

The virus, which had most likely originated in primates in Africa, had probably been infecting humans for close to a century, and had spread across the globe. Untreated HIV causes a slow destruction of the infected person’s immune system, leading to a plethora of opportunistic infections and cancers, known as the acquired immunodeficiency syndrome or AIDS.

Without treatment, almost all people with HIV progress to AIDS, and die. At its peak in the 1990s, around 1,000 Australians a year died from HIV/AIDS.

AIDS awareness painting on wall in Chimoio town, Mozambique. The text reads:
AIDS awareness painting on wall in Chimoio town, Mozambique. The text reads: "Be careful, always use a condom". (Photo: Ton RulkensFlickr)

HIV/AIDS mobilised western communities to act like never before. In Australia, a grassroots campaign led by communities most deeply affected resulted in a number of public health interventions and legislative changes. This included safe sex campaigns, needle exchange programs, and mandatory condom use and STI testing for commercial sex workers.

These changes led to reductions in rates of new HIV cases, while global investment in research and public health led to the development of “antiretroviral” drugs, which stopped the virus from replicating, helped control HIV infection, and markedly reduced the risk of progression to AIDS.

To date, about 40 million people have died from AIDS, and an estimated 36.7 million are living with HIV. Nevertheless, most people affected by HIV in western countries live a long and healthy life.

Although an effective vaccine for HIV is not available, progress is being made in diagnosis, reducing transmission and improving the health of those affected.

Treating those with HIV to a point where the virus isn’t detectable in their blood reduces the possibility of onward transmission by 90-95%. And it leads to numerous individual health benefits for the infected individual. In contrast, uninfected people at high risk of contracting the virus can take antiviral medications known as pre-exposure prophylaxis that prevent infection. These have shown to be highly effective if taken properly.

There are hopes these treatments will end the epidemic by 2030.


It’s easy to forget about the danger of influenza. In most cases, this virus is responsible for a respiratory illness of varying severity that generally doesn’t require treatment. However, influenza has been responsible for more deaths in the last century than HIV/AIDS.

Usually, seasonal influenza outbreaks occur annually and affect around four million people, with about 250,000 deaths worldwide. Typically older patients, with pre-existing illnesses such as heart failure or chronic lung disease, and pregnant women are at the greatest risk of death.

Many people have a degree of immunity, due to vaccination or previous infection. It’s worth noting that although safe, the influenza vaccine is imperfect; it’s developed using strains of influenza virus circulating in winter, in the opposite hemisphere, and is about 50% effective at preventing infection. But vaccination is still an important strategy to protect those at risk of most severe infection. It reduces hospital admission and symptomatic infection.

Occasionally, an influenza virus not usually seen in humans is transmitted from its reservoir in aquatic birds, poultry or pigs, to humans. As a consequence, those exposed have no natural immunity, and are not protected by the vaccine at all. If this virus evolves to readily infect and spread between humans, it can have devastating consequences.

In the last century, this has happened several times, with numerous fatalities. The Spanish influenza pandemic of 1918 led to the deaths of more than 40 million people; more than double the number of fatalities in the First World War in the preceding four years. It progressively spread around the globe, with the modernisation of transport and trade systems, and mass-movement of military troops.

In more recent times, smaller outbreaks have occurred, with bird flu and swine flu. There is an ever-lingering threat of a repeat influenza pandemic, due to the industrial scale farming of chickens and pigs, that are also susceptible to infection and the close proximity of humans to these animals.

Due to the rapid and fluid movement of people around the globe for business and leisure, a new pandemic virus could easily be transported around the world. In recent years, countries have stockpiled influenza medications and vaccines in preparation for a possible influenza pandemic.

These are only four of the infectious diseases that have shaped the last century. In reality, there are a number that could have been included in this list of threats including polio, malaria, cholera and syphilis.

Each of these diseases is very different, and as such, our responses to them have been very different too. In part this is because quite different organisms cause these infections, but it’s also because the social context in which diseases happen is critical.

If we are to save the world from the threat of infectious diseases, we need to learn the lessons of past outbreaks, including the value of international collaboration, perseverance and commitment to humanity.

This article was first published on The Conversation.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the marketing team and not by the editorial staff.