Q: How does understanding the evolution of virulence help us to
manage infectious disease?
A: For most of the last two centuries people have been using
interventions to knock down infectious diseases as much as possible.
The idea is that we're going to use weapons like vaccines and antibiotics
or hygienic interventions to reduce the frequency of infection as much
My point is that there's another way of controlling these disease
organisms. Instead of using these weapons -- antibiotics and vaccines
and hygiene improvements -- as a way of knocking down the organism,
we can use those interventions to control the evolution of the organisms
instead of getting the organisms evolving around our interventions. We
can get the organisms to evolve to be less harmful than they have been
in the past. Essentially, what I'm saying is we can use interventions
like vaccines or like hygienic improvements to domesticate these
That argument may seem a little bit surprising, but we've already
domesticated organisms in many ways. One of the most obvious ways is
when we make live vaccines in the laboratory. We're actually taking
harmful organisms [and] changing the course of their evolution, making
them evolve to be mild enough that we can then introduce them into
people as a vaccine.
Q: Give us a new way to look at disease organisms.
A: Some people think that disease organisms are out to get
us -- any false move and we'll be damaged or even killed by them.
Other people think that disease organisms really, in the best of
all worlds, would be so mild that we wouldn't even know that they're
there. And the truth is that both of those explanations are right,
and disease organisms can be anywhere in between.
I think the right way to look at them is that we're the environment
for them and, in some cases, our health is important for their
well-being, particularly if their transmission depends on our being
healthy. You've got a lot of organisms that are living in and on us
that cause us no detectable harm whatsoever.
In fact, we wouldn't want to be getting rid of all of the organisms
that live in and on us because many of them are protecting us against
other organisms. If we can favor those mild organisms, then they can
protect us against the harmful organisms. I think that will be one
of the goals of medical work in the next century, especially for those
disease organisms that seem to be totally unresponsive to the attacks
that we impose on them from antibiotics or vaccines.
Q: Tell us about that transmission strategy -- how a disease
organism tries to reproduce, how it tries to get to the next host --
and then tell us how that relates to its virulence.
A: I would say that disease organisms are selected to compete
with other disease organisms, that's the bottom line. So if a disease
organism is transmitted in a way that requires a healthy host, the best
competitors will be those disease organisms that are mild enough to
keep their host healthy to allow themselves to be transmitted.
By focusing on the mode of transmission for disease organisms we
can gain a lot of insight into why some disease organisms are harmful
and other disease organisms are mild. For example, a disease organism
like the rhino virus that causes a common cold really does depend on
fairly healthy people to be transmitted. So, not surprisingly, the
rhino virus is one of the mildest viruses that we know about. In fact,
nobody has ever been known to die from a rhino virus, and that's not
true for almost any other disease organism of humans for which we have
ample information. Almost all the other disease organisms will cause
enough damage so that some people might die, if they're particularly
So, in the case of these mild organisms like the rhino virus, if a
person happened to be housing a virulent mutant -- these mutants are
happening all the time, even in the mild organisms, mutations that
might make it a little more harmful or a little less harmful -- then
you can ask the question, "Will that organism spread?"
The rhino virus is transmitted when people sneeze on other people,
or maybe people sneeze in their hands and then they shake hands with
other people, and those people then may touch their nose with those
contaminated hands. Given that those are the main routes of transmission,
it's clear that if we had somebody who is infected with a particularly
harmful variant of the rhino virus, a variant that was so harmful that
the person would have to stay in bed, that even though that virus
might be reproducing a lot more in the short run, in the long run that
organism would lose out in competition. A person who is stuck at home
in bed is not going around sneezing on their friends. An immobilized
person is not going to be a major source of transmission for something
like the rhino virus. That explains why the rhino virus has evolved to
be fairly mild.
At the other extreme we've got disease organisms like the protozoan
that causes malaria, which can be very harmful. What's especially important
in this context is that if the organism is harmful, so harmful that the
person can't move from bed, the organism, at least in many parts of the
world, can [still] be readily transmitted to other people because a
person who's sick, maybe delirious in bed, is a sitting duck for
Mosquitoes can bite that person more effectively than a person
who's feeling very healthy. So in this case we expect that natural
selection would actually favor those variants of the malaria organism
that exploit the host fairly ruthlessly. A sick person's less likely
to swat a mosquito. So, in that case we expect that these disease
organisms that are transmitted by vectors, things like mosquitoes,
should evolve to be among the most nasty of human pathogens and
that's, in fact, what we find.
We find that the vector-borne disease organisms, disease organisms
transmitted by things like mosquitoes or sand flies, tend to be much
more damaging than the disease organisms that are transmitted by
people walking around sneezing or coughing on other people.
Q: Let's talk about waterborne diseases.
A: Diarrheal disease organisms can be transmitted in
several different ways, and at least one of those ways also allows
the organism to be transmitted from very sick people -- that way
is waterborne transmission. If a diarrheal organism is transmitted
by water, then even a very sick person can serve as a source of
infection for hundreds or even thousands of other people.
How does that work? If you were living in a place like Bangladesh
or Ecuador, a place in which water supplies are not well protected,
and you imagine somebody who is infected with a particularly ruthless
strain of a diarrheal bacterium, that bacterium may be reproducing
to a very high level and thereby causing the negative effects that
we see in the sick person. In the process of reproducing, it's
gaining competitive advantages against other organisms by shedding
tremendous numbers, maybe as many as a billion organisms from a
single infected individual. And because that person's not moving,
those organisms are released into clothing or bed sheets, and they
don't stay there -- somebody else will come along, take that
contaminated material, maybe wash it in a canal. The canal water
may drain into drinking water, or people may come to the contaminated
water and gather that water and bring it back in the house. Maybe
some system for distributing water will go to a contaminated source
and distribute it to large numbers of people. That whole process is
analogous to a swarm of mosquitoes moving from one infected individual
to large numbers of susceptible individuals.
[We] refer to those cultural analogs of vectors like mosquitoes
as "cultural vectors." Waterborne transmission is part of a cultural
vector that allows transmission to occur from very sick people, and,
in so doing, would tip the competitive balance in favor of the more
nasty exploitative variance in the disease organism population. As
a consequence, if you have contaminated water allowing transmission
of disease organisms, we expect those disease organisms to evolve
to a particularly high level of harmfulness, and that's exactly what
If we look at the bacteria that cause diarrhea and we quantify
how dependent they are on water as a mode of transmission, we find
that the more waterborne bacteria are much more harmful. The worst
of all of the diarrheal bacteria that we know of have been waterborne
bacteria. [For] example, the bacteria that cause cholera are often
waterborne. Bacteria that cause typhoid fever are often waterborne.
Bacteria that cause the worst of the bloody diarrheas that we call
dysentery are waterborne.
As a consequence, if waterborne transmission [is] very prevalent
in an area, then we expect that the diarrheal disease organism should
evolve to become more exploitative, using us more extensively as their
food sources, and thereby become more harmful to us. If, instead, we
clean up the water supplies, then we force the disease organisms to be
transmitted only by routes that require healthy people. So what we
should be finding if we clean up water supplies is that we drive the
organisms to evolve toward mildness.
And that's a very powerful idea, because when you clean up the
water supply, the only routes that are left for transmission are routes
that require people to be fairly healthy. So the new view would say if
you clean up the water supply, we'll get far more benefit than we'd
expect, because in addition to reducing the frequency of infection,
we'll also mold the organisms -- evolutionarily, we'll force them to
evolve to mildness.
The evidence from the literature indicates that, in many cases, we
could have forced them to evolve to be so mild that almost nobody would
be killed. In fact, most people wouldn't even know they're infected.
They would have infections that are asymptomatic; that is, people are
carrying around the organism and the organism's generating some immunity
in them and so it's providing some protection against the other organisms,
but the person who's carrying the organism around doesn't even know that
he or she's infected.
Q: Let's talk about disease organisms that can survive outside the
host in various conditions.
A: As we look at respira-tract pathogens, we still see a lot
of variation in harmfulness of disease organisms. At one extreme we have
very deadly organisms like the smallpox virus, or the bacterium that
causes tuberculosis. At the other extreme we have the very mild disease
organisms like the rhino virus that causes the common cold. So that
raises the question: Why do we have this variability? Well, evolutionary
theory provides us with an answer. In particular, evolutionary theory
focuses on whether a disease organism can be transmitted from somebody
who is very ill with an infection.
One of the ways in which disease organisms can be transmitted is by
being durable in the external environment. If we imagine a disease
organism that could last for 10 years in the external environment,
even if a person who's infected is immobilized, coughing or sneezing
or shedding one way or another, many people may come to that spot in
the next 10 years, so that immobilized person could still serve as a
source of infection for many susceptible individuals.
What we expect, if that argument's right, is to see an association
between how durable the disease organisms are in the external environment
and how harmful they are. And that's exactly what we see. At the top of
the list is the smallpox virus, which can last, in some cases, for more
than 10 years in the external environment, and it's the most damaging
of all the respiratory tract infectious agents of humans. Next on the
list would be the tuberculosis bacterium, which is also quite durable
in the external environment. It's also a very damaging pathogen.
If we look at disease organisms like the rhino virus that causes the
common cold, we find that it loses its viability within a few hours
after being sneezed out. So it's not too surprising that it's very mild.
It really does depend on people coming in close contact with other people,
getting out and moving around in the environment, whereas the virus that
causes smallpox doesn't depend on that mobility nearly so much.
Q: Summarize your theory and your ideas natural selection and
transmission of disease organisms.
A: We can summarize this information in a nutshell by focusing
on how dependent disease organisms are on the mobility of the host for
transmission. If a disease organism is very dependent on healthy hosts
moving around [and] contacting susceptible hosts, then we expect
natural selection to favor extreme mildness in those disease organisms.
If, however, the disease organism is not dependent on host mobility --
for example, if the disease organism's transmitted by mosquito, or
contaminated water, or because it's durable in the external environment
-- then we expect that natural selection will favor high levels of
harmfulness in those disease organisms.
Q: Given that we have this information, how do we apply it?
A: Once we understand the factors that favor increased
harmfulness and decreased harmfulness, then we can ask the question,
"Can we do certain things that would favor organisms evolving toward
In some cases we might want to have a harmful organism -- for
example, if we were generating an organism to control an agricultural
pest. But in terms of human diseases, generally it's in our interest
to have the disease organisms be as mild as possible.
What we can do depends on the particular category of disease
organism we're looking at. For example, for diarrheal disease
organisms, we know that waterborne transmission should favor the
harmful competitors among those disease organisms. If we clean up
the water supplies, we should be favoring the milder competitors.
When we look at the population of disease organisms in any given
area, we see both mild and harmful strains. The mild strains are
there, sort of hanging on; all we need to do is tip the competitive
balance in favor of those mild strains.
One way we can do that is by investing in clean-up of water supplies
and also investing in adequate sewage disposal. If we do that, then
we should get not only the benefit that most people would recognize --
reduced frequency of infection in the population -- but also we should
be molding those disease organisms toward mildness. We should be taking
control of the evolution of those disease organisms, favoring those
mild strains and thereby essentially domesticating those disease
organisms, making them into mild versions of what was there before.
With a mild version, most people won't even know they're infected.
It'll be almost like those people having a free, live vaccine, and,
like a vaccine, those mild organisms can generate immunity that will
protect against harmful organisms that might arise through mutation
or might come into the area as a result of infiltration from other
countries which hadn't cleaned up their water supplies.
We can look at the experience in South America and Central America
as a kind of a natural experiment that allows us to evaluate these
ideas. In 1991, cholera came into Peru and then quickly, within a
couple of years, spread all throughout South and Central America.
Some countries had clean water supplies, and other countries had
contaminated water supplies. What we find is that when the organism
invaded countries with clean water supplies, the organism dropped in
In contrast, the organisms that invaded countries with poor water
supplies, countries like Ecuador, evolved increased harmfulness over
time. They've actually become more toxigenic -- they produce more
toxin than they did at the outset. So that's very worrisome for those
countries with poor water supplies. It means that the next time
conditions are ripe for a cholera epidemic, they may have a worse
problem than they've had in the past.
Q: Most people don't think that we actually are affecting
evolution in any way.
A: Many people think of evolution as something that takes
a long period of time, something that might require millions of years.
But the truth is that evolution can occur very quickly -- and especially
from microbes, it can occur very quickly. One can get evolutionary
changes in antibiotic resistance over a period of just a few weeks,
if the use of the antibiotic is extensive enough. And so with disease
organisms -- because they're dividing so quickly, because they can
generate mutations at a rapid rate, because they can share their
genetic information among the different members in that population --
evolution can occur very quickly.
We need to think about evolution on a time scale of months to
years in terms of our intervention strategies and, unfortunately,
people just haven't been thinking about it in that way. Mainly,
people have been thinking about evolution as a source of problems
rather than a source of solutions. For example, when people are
looking at the antibiotic resistance problem, they see evolution as
sort of the bad guy -- it's the evolutionary process that's led to
antibiotic resistance. That's true, but just as easily we can have
evolution being the solution.
In other words, we can have evolutionary processes leading to
organisms becoming more mild over time, and if organisms become
more mild, then we've solved the problem. Not by getting involved
in some kind of arms race in which we're using one antibiotic weapon
against the organism, and [the organism] evolving a defensive weapon
against that antibiotic, and then we have to shift to another, and
so on, indefinitely. Instead, we have a sense of where we want
evolution to end, and we adjust the environment so that the organism
freely evolves to that endpoint, which is in its interest and also
in our interest.