The Incidental Tourist Read online

  Well, you are at absolutely no risk if the bug in question is transmitted via an insect (mosquito, biting fly) vector, such as Zika, Chikungunya, dengue, malaria or sleeping sickness. And you can protect yourself against most things if you follow the basic rules of hygiene: wash your hands thoroughly when you use the toilet, avoid (so far as that’s possible) touching hands to face and don’t pick your nose – apologies for being so indelicate, but it’s best to be practical and confront such issues. Do that, and you have a pretty good chance of avoiding cholera, typhoid and worms. The bugs you have to worry about on a plane are the respiratory ones, like flu and tuberculosis, though hand washing will also provide a good measure of protection against them – some people carry a small bottle of hand sanitiser.

  Be aware that some bugs survive on contaminated surfaces, or fomites, as the professionals call them. During the SARS (severe acute respiratory syndrome) epidemic in late 2002 to mid 2003, for example, people in affected countries, notably China, were employed to go around and disinfect public door handles, elevator buttons and stair rails at frequent intervals.

  To avoid a respiratory virus you obviously can’t just stop breathing. But do be reassured that these bugs are not distributed round aircraft cabins through the recirculating air systems of planes. These filter them out, even such small particles! The science done suggests you are at greater risk if you are seated on the aisle, or within three rows of someone who is coughing and spluttering. I haven’t noticed other people popping on facemasks, though. And unless such masks are elaborate, and thus an unlikely item to have in your carry-on luggage, they probably aren’t all that much use anyway. In days gone by, the eminent immunochemist Elvin Kabat travelled everywhere with his gas mask, but I understand he carried a medical certificate explaining that he was incredibly allergic to tobacco smoke – back in the day when people were still allowed to smoke on planes and you could never really get away from the stuff! But would you really want to explain to airport security today why it is that you’ve packed a gas mask?

  How do we get infected with anything anyway? The bug (micro-organism or pathogen, if you want to be more elegant) has to get into our body somehow. Either it must to go through the surfaces that protect us from the environment (skin, the mucous membranes that line the orbit of the eye, and the respiratory, gastrointestinal and reproductive tracts); be injected via the proboscis of a feeding mosquito, the bite of a tsetse fly (sleeping sickness) or the bite of a carnivore (rabies); or inserted by a ‘stick’, such as a contaminated needle (hepatitis C, HIV). On a plane, it’s only the stuff that comes in via the mucosal surfaces that poses a risk (measles is notoriously infectious via this route). The mucosal epithelium that lines our nose, trachea, bronchi and lungs, for example, has receptors that bind to some forms of the flu virus, allowing particles to enter our cells and begin the process of replication and further infection that ensures their survival, yet may compromise ours. (I wrote a much more detailed discussion of infection and immunity in Pandemics: What everyone needs to know.)

  All this simply brings us to the question of pre-existing immunity or ‘being immune’, which, in turn, takes us to a discussion of what everyone should do long before boarding an international flight, especially if it is to an exotic destination: make sure your immunisation record is up to date. If you’re in a large city, go to a specialised travel clinic; otherwise, consult your doctor – keep in mind we’re talking about a university trained MD (or MB, BS), not an osteopath or some ‘holistic’ or ‘natural medicine’ practitioner. In order to achieve full protection, you need to start this process at least six weeks before you board the plane.

  If you can’t produce evidence that you’ve been vaccinated, or remember if this happened some time back, the doctor will insist that you receive all the standard childhood vaccines, and likely add hepatitis A for good measure. There’s no harm in this – boosting pre-existing immune memory can only be beneficial and you will be better protected. Vaccine-induced protection against water-borne diseases like typhoid and cholera, for example, falls off pretty quickly. Many of the paediatric infections, particularly rubella and mumps, can be much worse if you encounter them for the first time as an adult – males might suffer permanent sterility. And, if you’re travelling to somewhere like West Africa, it is mandatory that you receive the yellow fever vaccine – this terrible disease kills, on average, more than 25,000 Africans a year, and you don’t want to join that list!

  Your doctor will also assess if you need to start taking antimalarial drugs. Be aware, though, multi-drug resistant forms of malaria are active through much of the tropics, though there is no endemic malaria in northern Australia or in the southern United States. Malaria, like dengue and Zika viruses, is carried by mosquitoes, so you should also purchase and use a good-quality insect repellent, as there are many mosquito-borne infections. Some, like Zika, have only recently come to the fore, while others that probably cause occasional human disease, lumped together as PUOs (pyrexias, fevers, of unknown origin) with (often) odd brain symptoms, are poorly understood. The only protection you have is to wear long trousers, a long-sleeved and light-coloured shirt, use a mosquito repellent and sleep in a screened room or under a bed net.

  The travel clinic may also offer to sell you a ‘gastro’ pack. Buy it! We’re not talking about gastronomy, but gastrointestinal disease, particularly low-grade Escherichia coli infections characterised by throwing up and diarrhoea – think Delhi belly, Montezuma’s revenge. Included will be some broad-spectrum antibiotics and packets of physiological salts that can be dissolved in clean (boiled or bottled) water to counter dehydration. Be careful, though: self-medication is always risky. If you have a high fever it could be something much worse (malaria), so consult a doctor immediately if your symptoms are very severe. Usually your hotel or travel director can arrange for you to be seen by a professional.

  There are, of course, no guarantees that we can avoid becoming infected with some exotic pathogen when we’re travelling, especially if we are more courageous and venture into tropical rainforests and caves. There are (at time of writing) no vaccines for many (particularly) tropical diseases, like Zika and Chikungunya. A partially effective vaccine for dengue has recently become available in some countries, and there is evidently a ‘strategic pool’ (unavailable to the general public) of Ebola vaccine for use in the next, and inevitable, outbreak.

  Overall, when it comes to adventure travel and readily communicable diseases, we do have a clear responsibility to ourselves, to our families and to our fellow citizens. Keep the possibility of infection at the front of your mind, take reasonable precautions, embrace proven preventive measures and don’t ignore any sudden, severe fever and/or diarrhoea. Some of these conditions can go bad very, very fast.

  CHAPTER 3

  Italy, off the beaten track

  SOME OFFERS CANNOT BE refused. This was certainly the case when I received the summons to give the 2015 Rita Levi-Montalcini Lecture at an intriguing, local science festival called BergamoScienza. Though Padua and Bologna, those other northern Italian cities that fostered the great medical schools of the European Renaissance, have long been on my personal radar, Bergamo was just a name. Reading the invitation, the opportunity to participate in a free-to-all celebration of science and enquiry that aims to intrigue and inform any (especially young) citizen who cares to attend was a big attraction. But the main hook was the association with a true hero of twentieth century science.

  Rita Levi-Montalcini (1909–2012) grew up in Turin (a two-hour drive from Bergamo). While we never met, my early background in brain pathology (she was a developmental neurobiologist) and the fact that she was a prominent public advocate for science (and supporter of BergamoScienza) meant that I was well aware of her. Levi-Montalcini was a co-recipient (with Vanderbilt University’s Stanley Cohen) of the 1986 Nobel Prize for Medicine, and was also appointed by the president of Italy as Senator for Life (from 2001) in the upper house of the national Parlamento della
Republica Italiana.

  No doubt Levi-Montalcini spoke out strongly for the value of looking at public policy through the prism of actual evidence, though, as with any scientist who deals directly with politicians, there must have been a high level of mutual incomprehension. Even so, given that many of the profound changes in our world are driven by science and technology, along with the ethical challenges that new knowledge raises for both policy and the law, finding some mechanism for getting at least a small measure of scientific understanding into politics does seem like a reasonable idea. At least until recently, Britain appointed leading scientists (including Sydney Boys High School/University of Sydney-educated Bob May and Geelong Grammar/University of Melbourne-trained Alec Broers) to the House of Lords. Few professional scientists will take up the challenge of seeking elected office, though Germany’s Angela Merkel (a physics PhD) is an exception. There were also three PhD physicists, Rush Holt, Bill Foster and Vernon Ehlers, in the 110th (2007–09) US Congress.

  Qualifying first as an MD, Levi-Montalcini was dismissed from her assistant professorship in anatomy at the University of Turin when Benito Mussolini’s National Fascist Party passed a 1938 law banning all Jews from academic appointments. Having some family resources, and maybe as a result of good luck and a move from Turin to Florence, she and her twin sister Paola (a well-known artist) avoided the fate of being transported to Auschwitz. Fellow Turin scientist and author, the industrial chemist Primo Levi, did not, and he describes in If This is a Man how he survived that ordeal due to his technology skills. Continuing to do investigative work in a laboratory set up in her bedroom, Levi-Montalcini spent much of the Second World War focused on the factors determining nerve growth in chick embryos – even in wartime, it was possible to get hold of fertilised hen’s eggs!

  In my field, a great deal of important virology and immunology research was done initially with chick embryos (especially by Sir Macfarlane Burnet, as I described in Sentinel Chickens: What birds tell us about our health and our world) but I was only peripherally aware of Levi-Montalcini’s work with developing chicks until, seeking to acknowledge her achievements at the beginning of my Bergamo lecture, I looked into her career more closely. As often happens when I read about the lives and contributions of leading biologists of an earlier era, I find a record of dedication and intellectual clarity based on simple, elegant experimentation and insight. She was continuing a great Italian tradition. The science of embryology started in the seventeenth century when, working in Bologna, Marcello Malpighi described the progression he saw when he examined chick embryos at different stages of development.

  Early vertebrate evolution followed common pathways for birds and for us and, even in an era where human dissection was forbidden, the all-controlling Church of Rome could hardly object to cracking open hens’ eggs. Remarkably, some religious fundamentalists believe that embryology, in the words of US Republican Congressman (2007–15) Paul Broun, ‘lies straight from the pit of hell’! Given that such research just describes what’s actually there, it’s hard to comprehend a mindset that finds the most obvious realities of biology to be obnoxious. Remarkably, Broun is a medical doctor!

  After the liberation of northern Italy in April 1945, Levi-Montalcini volunteered her medical services to help the allies in Florence. She then moved to the United States to continue her focus on nerve growth in the research group led by eminent émigré German/Jewish developmental biologist Viktor Hamburger at the Washington University of St Louis. There she also began her professional association with biochemist Stan Cohen, her co-Nobel Prizewinner. Appointed as full professor at Washington University in 1958, Levi-Montalcini was, by 1961, directing the Research Centre for Neurobiology in Rome. Thereafter, while continuing her US collaborations, she saw out her research career in Italy. Washington University and Vanderbilt (in Nashville) are, incidentally, the two closest, major research universities to St Jude Children’s Research Hospital, my other (than the University of Melbourne) scientific home.

  Travelling to Bergamo, Penny and I flew from Memphis to Miami, then on to Milan’s Malpensa airport. This was our second visit to Milan, as we’d spent five days here at the 2013 International Immunology Congress. On that earlier trip, we used a few spare hours to visit the local historical sites, especially the magnificent mosaics at San Lorenzo Maggiore, and the enormous gothic Duomo (cathedral) with its associated plaza. And we also stumbled into the much more intimate (and somewhat dilapidated) church of San Gottardo, dedicated to Saint Gottard of Hildesheim, the patron saint of gout. Recent work from the laboratory of the late Jürg Tschopp and others suggests that treating patients with a monoclonal antibody that neutralises the cytokine interleukin 1β (normally an immune defence molecule) is more therapeutically effective than praying to Saint Gottard, but gout is a painful condition and we go with what’s available!

  Getting special treatment as the principal guest lecturer for the Bergamo festival, a driver collected us at Malpensa and, a bit dazed from the overnight flight, we headed north through the extensive industrial area of Milan. Unlike the situation too frequently encountered in 2015 Australia and the United States, we were not seeing dilapidated and abandoned factories – at least when it comes to high-end products (Maseratis and haute couture), the Italian way of doing things does have some things going for it! In less than ninety minutes, we turned off the highway to enter the modern city of lower Bergamo, then the road climbed steeply upwards and, entering through one of the many gates in the intact sixteenth century wall, the driver navigated the winding ways of mediaeval upper Bergamo.

  Spanning a vertical distance of 85 metres, the upper and lower sections of the city are linked by a steep funicular railway (240 metres at a gradient of 52 per cent), which obviously serves a useful function by limiting car usage in the old town. As we discovered later, there’s a second funicular (the San Vigillio) going up to the Parco dei Colli that faces the surrounding green hills, valleys and villas of Lombardy and looks back to the many churches, towers and chimneys of compact, historic upper Bergamo. Embarking on this short trip in the middle of the day could, unless you’re prepared to walk down a steep hill, mean signing up for a visit to one of the several restaurants at the top as the funicular driver will take a couple of hours off for lunch – northern Italy retains some of the congenial aspects of a Mediterranean lifestyle.

  Arriving at our destination in upper Bergamo, we were dropped street side at the tall, narrow Gombit Hotel. With only thirteen rooms built into what was a thirteenth century tower house, its bright, contemporary furniture mandated by designer Giò Pozzi contrasted dramatically, as we reached our room from an open walkway, with the weathered vertical stone dropping to a small courtyard. And just beneath our window was a monument to the nineteenth century emergence of sanitary science: a roofed-over, communal wash house (for clothes). The tubs of this 1881 lavatoio are supplied with clean water and a drainage system designed to minimise the possibility of a cholera or typhoid outbreak. No doubt accommodated more comfortably than the traditional owners, the twenty-first century transients who occupy the tower today enjoy central heating, ensuite bathrooms and the usual continental breakfast of fruit, breads, preserved meats, cheese and coffee.

  Pretty much any place of interest in old Bergamo was only a few minutes walk away. During the day, the narrow streets were full of tourists, who seemed to be mostly Italian. Some were there for the science festival, but it also seemed that many were people of faith visiting the various religious sites. Intended to warn the citizens that the gates were closing, the nightly 10 pm sounding of a hundred bell peels from the twelfth century Il Campanone reminded us that this is a city with a deep ecclesiastical history. Like the muezzin call from mosques in the Arab world, what had been the work of energetic devotees was now a recording.

  The next day we took it easy and wandered around, as there wasn’t much to do until I gave my lecture the following day. This was to be held at the Teatro Sociale, about two minutes walk from the h
otel. Completed in 1808 and influenced by the design of Milan’s much larger La Scala Opera House, the Teatro served as both a theatre and a home for community events, then it fell into progressive disuse from 1929 and was almost demolished. My sense was that the Teatro had been founded to provide a public meeting place that had no measure of church control and then, since Mussolini’s 1922 elevation to power, it lost its relevance as the fascists strangled open debate. An enormous effort was required to bring it back after eighty years of neglect – much of it, especially the tier-on-tier wooden boxes, had become very unsafe. It was sensitively restored and, in 2009, the Teatro returned to general use.

  The science meeting ended on the Saturday but I’d been asked to stay on through Monday to give the graduation speech at the University of Bergamo. Down the hill, this relatively new institution (1986) is housed in the cloistered campus of a former (from the sixteenth century) Capuchin Monastery. My Rita Levi-Montalcini lecture at the Teatro Sociale had simultaneous translation (English and Italian) and that was also true for several other keynotes by imported speakers. But it wasn’t the case for the majority of the talks, as I discovered when I walked over to hear Antonio Lanzavecchia, a long-term immunology colleague. Realising that this might be the case for my university address, I provided a written text, anticipating that an Italian version might be handed out. Though a brief account did appear in the local paper, there was no translation available on the evening. It seemed my words of wisdom for the Bergamo graduates were likely even more irrelevant than is usually the case, though people listened politely. In such situations, the advice of Polonius (Hamlet Act 2, scene 2) that ‘brevity is the soul of wit’ is spot on!