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Emerging
Infectious Diseases
This page intentionally left blank
Emerging
Infectious Diseases
Art in Science polyxeni potter

center s for dise a se

control and prevention
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research,
scholarship, and education by publishing worldwide.

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Published in the United States of America by
Oxford University Press
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© Oxford University Press 2014

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted by law,
by license, or under terms agreed with the appropriate reproduction rights organization.
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to the Rights Department, Oxford University Press, at the address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

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ISBN 978-0-19-931569-7

9 8 7 6 5 4 3 2 1
Printed in China by
Asia Pacific Offset
Oxford University Press is proud to pay a portion of its sales for this book to the CDC Foundation. Chartered by Congress, the CDC
Foundation began operations in 1995 as an independent, nonprofit organization fostering support for CDC through public-private
partnerships. Further information about the CDC Foundation can be found at www.cdcfoundation.org. The CDC Foundation did not
prepare any portion of this book and is not responsible for its contents.
Contents
Foreword vii

Preface: Arts, Science, and the Pursuit of Knowledge ix

Acknowledgments xvii

disease emergence 1

Everything Flows, Nothing Stands Still 7

Host-Pathogen-Venue Combinations and All That Jazz 11

The Panoramic Landscape of Human Suffering 14

Oneness, Complexity, and the Distribution of Disease 17

Molecular Techniques and the True Content of Reality 23

Chiaroscuro in Art and Nature 26

Art, Science, and Life’s Enigmas 29

microbial adaptation
and change 33

Not from the Stars Do I My Judgment Pluck 38

Ancient Myths and Avian Pestilence 42

The Human Face of Pestilence 45

Nature Hath Fram’d Strange Fellows in Her Time 48

Corona of Power or Halo of Disaster 52

Much Madness Is Divinest Sense 55

Drugs, Microbes, and Antimicrobial Resistance 58

climate, weather, ecosystems 61

I Am but Mad North-Northwest: When the Wind is Southerly

I Know a Hawk from a Handsaw 66

The Icy Realm of the Rime 70

North American Birds and West Nile Virus 74

Trouble in Paradise 77

Of Tidal Waves and Human Frailty 80

Memory and Imagination as Predictors of Harm 84

Manifesting Ecologic and Microbial Connections 88

economic development
and land use 91

Rowing on the Schuylkill, Damming on the Yangtze 95

The Soot That Falls from Chimneys 99

 And Therefore I Have Sailed the Seas and Come to the Holy City
of Byzantium 103

Landscape Transformation and Disease Emergence 107

Phoenix and Fowl—Birds of a Feather 110

Paleolithic Murals and the Global Wildlife Trade 113

Optics and Biologic Connectedness 117

human demographics
and behavior 119

A Flea Has Smaller Fleas That on Him Prey; And These Have Smaller
Still to Bite ’em, and So Proceed Ad Infinitum 124

Persistence of Memory and the Comma Bacillus 128

Exotic Pets and Zoonotic Puzzles 132

Human minus Three Pieces of Hair 135

I Rhyme / to See Myself, to Set the Darkness Echoing 139

Protect Me, Lord, from Oil, from Water, from Fire, and from Ants and
Save Me from Falling into the Hands of Fools 144

The SARS Patient 147

technology, industry, travel,

and commerce 149

Hazards of Travel 154

Tango with Cows 157

Genre Painting and the World’s Kitchen 161

In Dreams Begin Responsibilities 164

“One Medicine” for Animal and Human Health 168

Pale Horse, Pale Rider Done Taken My Lover Away 171

The Way Forward Is the Way Back 175

poverty and conflict 177

Scientific Discovery and Women’s Health 182

How Comes It, Rocinante, You’re So Lean? I’m Underfed, with

Overwork I’m Worn 185

What Did I Do to Be So Black and Blue? 189

Rats, Global Poverty, and Paying the Piper 193

The Face of Tuberculosis 197

Postal Work Now and Then 199

Art Is the Lie That Tells the Truth 202

Index 205

vi co n ten ts
Foreword

D
oes the world need yet another art book? In a word, yes. In fact, it desperately
needs a great many more art books. As Yogi Berra pointed out, it is déjà vu
all over again.
When the infectious disease leadership at the Centers for Disease Control and
Prevention posed a similar question in the early 1990s, they wondered whether the
world needed yet another infectious disease journal. They had some help in
addressing the question. That help came to them in the landmark 1992 Institute
of Medicine report, Emerging Infections—Microbial Threats to Health in the United
States, edited by Nobel Laureate Joshua Lederberg, arbovirologist Robert Shope,
and microbiologist Stanley C. Oaks Jr. Although other infectious disease and mi-
crobiology journals existed and flourished, none filled the public health niche that
was desperately vacant in the era when untreatable AIDS was raging, tuberculosis
was reemerging, and antimicrobial drug-resistant organisms were gaining a foot-
hold in the health care and community setting.
By taking as its mission to inform the academic and public health communities
about emerging infections, the fledgling Emerging Infectious Diseases journal
adopted a broad scope, one that encompassed not only clinical medicine and epi-
demiology but also microbiology, veterinary medicine, social science, and even the
humanities. Taking the view that readers were public health oriented meant that
they needed actionable information that they otherwise had little time to access or
even read.
Although infectious disease may arguably be called the most successful medical
specialty in history, microbes continually evolve and adapt to novel hosts, new geo-
graphic places, or climatic conditions. That is the challenge Emerging Infectious Dis-
eases readers face; emergence is a never-ending process when it applies to infectious
diseases. As Dr. Lederberg was fond of saying, “It’s their genes versus our wits.”
The contents of Emerging Infectious Diseases cover the global waterfront. Nearly
every issue has reports from nations on nearly all the continents, and articles ad-
dress human and animal infections related to all major categories of organisms.
The news is often not good, and analyses of the morbidity and mortality paint a
bleak picture. Since its earliest years, the journal’s editors sought to communicate

vii
 more than the epidemiologic and pathologic findings. They, largely led by Man-
aging Editor Poly Potter, wanted to depict the human aspect of emerging
infections—from pain and death to nobility and triumph. What better way to do
this than to place the human aspect right up front? The first few years of the jour-
nal’s publishing history reflect a certain amount of experimentation—the initial
covers merely listing the table of contents and cautiously moving toward color im-
ages, and more recent issues representing the concept in full bloom. A cross sec-
tion of covers and accompanying essays are included in this book.
As with its scientific scope, Emerging Infectious Diseases adopted a broad view of
art, seeking out images from artists from all nations, eras of history (from prehis-
toric to contemporary), genres, and schools of art, and as many media as the two-
dimensional print covers can accommodate.
Poly Potter has done a great service to the emerging infections community of
scientists. By assembling a collection of covers and essays, she has been more than
responsive to a frequent query: “Why don’t you publish a book of those beautiful
covers?” The question is now answered, and the goal of the book is less to review
the past than it is to stimulate thought about the future. We thought that the world
really did need one more art book, and we are glad that you found this one.

D. Peter Drotman
Editor-in-Chief
Emerging Infectious Diseases

viii foreword
Preface
arts, science, and the pursuit of knowledge

For there will be hard data and they will be hard to understand
For the trivial will trap you and the important escape you
For the Committee will be unable to resolve the question
For there will be the arts
and some will call them
soft data
whereas in fact they are the hard data
by which our lives are lived
—John Stone, “Gaudeamus Igitur: A Valediction”

J
ohn Stone, cardiologist and poet, was an expert on the mechanics of the human
heart, inside and out. When he submitted a manuscript for publication in
Emerging Infectious Diseases, he urged that the cover for that month show a
painting by Georges Rouault, Les Trois Juges (The Three Judges), c. 1936 (page xvii).
As the fledgling journal could not afford the copyright fee for this image, he ar-
ranged for payment through his own institution, Emory University in Atlanta. The
painting, a shock of blood red roughly forming the abstract figures of the judges,
made a spectacular splash and a fitting companion to his account of “a man . . . who
had walked and worked among us and died of love.”
Stone’s choice of art for his story about syphilis was unusual. Most authors sub-
mitting manuscripts for publication in science journals view art as graphic illustra-
tion intended to clarify or summarize, to provide a visual explanation of content:
epidemiologic curves, line charts, bar graphs, genomic trees, explicit photographs
of lesions, color representations of organisms under the microscope, images of
vectors or human and animal anatomic features. Fine art, the creative effort con-
cerned solely with beauty and collected in museums and galleries, is not the
authors’ usual choice, nor is it often found in science publication.
How did fine art become a cover option for a science journal, and how did Stone
know about it? Emerging Infectious Diseases, a public health journal published by the
Centers for Disease Control and Prevention, has drawn on fine art for its covers
nearly since inception in 1995 with the mission to promote the recognition of new
and reemerging infections and the understanding of factors involved in their pre-
vention and elimination. Charged with communicating the threat of these diseases,
their unpredictable course, and the inevitability of their emergence in time and

ix
 space, the journal reached out to a global audience from academia, laboratories,
clinical practice, public health, social sciences, and other disciplines. Stone was
part of this audience.
Intended as a communication tool, not an archive of science, Emerging Infectious
Diseases was designed to be inclusive rather than exclusive; to demystify public
health data: “here is what we found and here is what the findings mean for public
health”; and to reach out to a broad audience through electronic communication.
These goals called for a reader-friendly format and a unique profile that would en-
able it to fill a niche left open by well-established, venerable journals in the crowded
marketplace. Art was harnessed to elucidate the issues, seek solutions, and engage
the general reader in the process of disease prevention and control. As a result, art
became irrevocably connected with the journal’s unique profile. And, while fine art
on the cover of a science journal was not altogether new, linking the art with the
science inside was.
In print publishing, the audience can be narrowly defined: public health practi-
tioners in state health departments and academic institutions in the United States
and around the world. In electronic publishing, ease of access on the Web expands
the audience in unanticipated ways. And whereas print assumes a light spillover of
scientific or technical information to the public through the mass media, an elec-
tronic product must take into account the expanded audience: patients seeking
direct information about illnesses and treatment, students and researchers whose
first impulse is to turn to the Web for information, continuing education candi-
dates, and a largely unserved multifaceted international audience.
The diverse composition of its audience influenced both the content and format
of Emerging Infectious Diseases. A multidisciplinary audience requires definitions
explanations, clarifications, substantive editing of submitted articles for readability,
and features with broad appeal. “Another Dimension,” a section inviting thoughtful
essays, short stories, or poems on philosophical issues related to science, medical
practice, and human health was created for just this purpose, to explore science
and the human condition, fear and pain, the unanticipated side of epidemic inves-
tigations, how people perceive and cope with infection and illness. The section is
intended to evoke compassion for human suffering and expand the science read-
er’s literary scope. This is the category in which Stone submitted his short story
“An Infected Heart.”
Images for the cover of Emerging Infectious Diseases are selected for artistic quality
and communication effectiveness. As the images, drawn from all periods, prehis-
toric to contemporary, lend their beauty or poignancy to the covers of the journal,
they also illustrate ideas, raise consciousness, reveal truth, stimulate the intellect,
and fire the emotions. And while they are selected to attract readers, they also sur-
prise, delight, inspire, and enlighten them.
“How are images selected?” For their ability to invoke in the mind of the reader
subtle but lasting connections. Connections that unlock understanding, dispel con-
fusion, promote compassion. “According to Brueghel / when Icarus fell / it was
spring / a farmer was ploughing / his field / the whole pageantry / of the year was /
awake,” wrote physician and poet William Carlos Williams in his poem “Landscape
with the Fall of Icarus,” “unsignificantly / off the coast / there was / a splash quite

x prefac e: arts , s ci en ce, a n d t h e p u r s u it o f k n owl e d ge

unnoticed / this was / Icarus drowning.” Without imagery, without the brushwork,
or the verse, one may never hear the splash of “Icarus drowning,” the very point in
Brueghel’s painting, Williams’s poem, and public health research.
“Tell us about it.” The cover story, a regular feature used to discuss the artwork
and its connection with the contents of the journal, evolved by popular demand,
literally out of the readers’ wish to know the art and how it relates to them and to
what they do. The life of the artist, the period, and the work are good for a historical
backdrop. Through one of countless possible interpretations, the art moves the
discussion toward the human element in the work. The public health topic at hand
provides the “hard data,” which can always be elucidated in human terms. Suf-
fering is universal. The purpose of scientific endeavor is its alleviation, the better-
ment of humanity, and the improvement of the quality of life for all people.
The landscape of emerging infections is rife with plagues, from old, familiar ones
resurfacing to completely new, unknown ones destined to occupy biomedical research
for the rest of time, from malaria resurgence and dengue to SARS, from pandemic
flu and poverty-related illness to intentional use of biologic agents and antimicrobial-
drug resistance. These plagues cannot be addressed apart from the community,
which ultimately funds their investigation just as surely as it provides the surveil-
lance data, the study groups, and the statistical evidence. Public health research can
hardly be conceived apart from the human element: the people who become ill.
Art humanizes and enhances science content and educates readers outside their
areas of expertise about important unnoticed connections. Art accomplishes this
by infusing scientific findings with empathetic understanding—in a literal way,
through the faces and places of traditional painting or completely in the abstract
through new ways of seeing. Beauty, color, emotion, style, and the eccentricity and
vitality associated with the artists’ lives and times, against the formality of technical
prose, open up the possibility, indeed the capacity, for alternative interpretation of
data, by introducing the metaphor. The metaphor, according to Aristotle, owes its
strength to making possible “an intuitive perception of the similarity of dissimi-
lars,” by implying likeness. A bird is not human, but a single element in its appear-
ance can invoke humanity, just as a single element in a plant’s appearance can
distinguish its species.
Right and Left (1909), a painting by Winslow Homer (Figure 2), was used on a
cover in conjunction with avian influenza. The title is hunt jargon for using a
double-barreled gun to shoot two ducks in rapid succession. The hunter, on the
waves in some distance, is barely visible behind the flare of the shotgun. The aquatic
scene is witnessed from the birds’ perspective in the sky. Bird on the right, possibly
struck first, falls limply toward the ocean. Bird on the left, in direct range, makes
desperate attempt at exit as the second shot is fired. Or is the bird on the left stunned
from being hit first, in the back, while the other bird is diving to escape?
The “in your face” travel of the birds and bullets adds dramatic immediacy. Agi-
tated waters, a glaring eye, and the rocking boat underline violence. Dislodged
feather and ray of sunshine mark the fleeting moment. This scene, painted near
the end of Homer’s life when death must have been on his mind, seems the culmi-
nation of a lifetime of observation. In a few brushstrokes, the artist delivers the
ocean’s power, the vastness of creation, conflict in the world, riddles in nature. He

prefa c e: arts , s c ie n c e , a n d t h e p u r s u it o f k n o w l e d ge xi
 projects the birds and their plight, the hunter’s unimportance, even as he fires the
fatal shots. The ambiguity in their posture is the artist’s ambivalence about which
bird died first. The threat is imminent and inevitable. Death is certain.
The artist’s vision holds yet more ambiguity today. The sporting ducks deliver as
well as receive havoc. When they escape the double-barreled shotgun and fly off,
they may carry with them nature’s revenge, introducing new virus strains right and
left: to domestic animals or directly to humans, increasing risks for new pandemics.
As we stare into the hunter’s barrel in Homer’s painting, we could be the sitting
ducks.
The connection between the arts and science is not obvious to everyone, though
it goes all the way back to the philosophic origins of science (Latin scientia = knowl-
edge). The quest for knowledge started with the first humans, who traced their
understanding of nature and its creatures on the walls of caves millions of years
ago. The quest continued with ancient civilizations, among them the Chinese, who
delved seriously into astronomy and healing, the Babylonians and the Egyptians,
who collected volumes about nature and its creatures, and the ancient Greek phi-
losophers, who went beyond collecting facts to lay the foundations of natural his-
tory and biology. They mastered all then known disciplines: ethics, rhetoric,
astronomy, poetics.
Among the greatest thinkers of all time, Aristotle wrote extensively on logic,
physics, art, politics, economics, and psychology and made the first serious attempt
at classification of animals. In all his treatises, he frequently compared the works
of nature with those of art, advocating the superiority of the former. Aristotle was
not the last of the era in which nature was the realm of philosophy, but by the time
of his death, philosophers had become more concerned with metaphysics and
ethics, while the natural sciences fell to other specialists. With the increase of infor-
mation, establishment of libraries, and invention of the printing press, specializa-
tion became the norm, and graduates of higher institutions were given bachelor of
arts or bachelor of science degrees. The philosophic origins of science are still
implied in the doctor of philosophy degree, though educational systems have
largely institutionalized the deep dichotomy between the arts and science, despite
their common origins.
In a controversial lecture given at Cambridge University in 1959, British intellec-
tual C. P. Snow (1905–1980) first used the phrase “the two cultures,” referring to
the world of science and the world of arts to describe their separateness. Snow, who
was a physicist, as well as novelist and poet, described his own experiences as a
man who frequented both “cultures.” “There have been plenty of days when I have
spent the working hours with scientists and then gone off at night with some lit-
erary colleagues,” he wrote, in frustration. “Constantly I felt I was moving among
two groups—comparable in intelligence, identical in race, not grossly different in
social origin, earning about the same incomes, who have almost ceased to commu-
nicate at all, who in intellectual, moral and psychological climate had so little in
common, that instead of going from Burlington House of South Kensington to
Chelsea, one might have crossed an ocean.”
Snow’s experiences in 1950s London, likely representative of the thinking of that
period elsewhere, seem alive and well in our times. Amidst general enthusiasm

xii prefac e: arts , s ci en ce, a n d t h e p u r s u it o f k n owl e d ge

about the use of fine art on our journal covers, some readers do question the “gra-
tuitous” use of color by a publication about science, decrying the cost and profess-
ing little interest in links to other disciplines. Science reviewers routinely reject
Another Dimension manuscripts as “belonging in other venues,” even when the
science information given in lay terms is sound. And some in the art community
are skeptical about links to science. Copyright permission requests for art images
to use on the covers of Emerging Infectious Diseases have often been rejected by art
institutions on the grounds that the art has nothing to do with disease emergence
and might be degraded by any association with infection, even if the artists them-
selves have met untimely deaths from such infections or their community was
ravaged by the plagues detailed between the journal covers. “For you can be trained
to listen only for the oboe / out of the whole orchestra.”1
In one of his many portraits, Rembrandt van Rijn painted a Scholar in His Study,
1634 (Figure 3), seeking what Aristotle believed all humans naturally desire: knowl-
edge. “Clearly,” he wrote in his Metaphysics, “it is for no extrinsic advantage that we
seek this knowledge . . . since it alone exists for itself.” In the old volumes stacked
in front of him, the scholar searches for the truth about human existence, suf-
fering, danger, hunger, disease, and survival, knowing that life slips by before the
task is done.
Rembrandt himself searched for the truth in the subjects he painted, in the
common people whose complexity he sought to capture. And the penetrating
analysis and contemplation characteristic of his self-portraits show no less than
compulsion to know himself. His work expanded the world of knowledge, for he
did not paint semblance alone. He saw, recognized, and expressed inner values and
ideas, universal human traits, natural phenomena; explored, understood, and con-
veyed emotions; and defined, communicated, and commemorated all these. Piece
by piece, in individual paintings and collectively in his life’s work, he observed and
recorded morsels of truth, seeking to understand and capture it.
Whereas his scholar dwelled on words, Rembrandt used color and brushstrokes.
For these, along with numbers, notes on the staff, or sheer speculation, are the
tools for exploring the universe. And so it goes with science and public health. In
isolation like Rembrandt’s scholar, in the laboratory or in the field, public health
workers search, too, observing, recognizing and meticulously recording relevant
information, surveying, delving into the unseen and implied, and expanding
knowledge. Emerging Infectious Diseases covers seek to bring forth this connection.
Despite continued specialization and a steady drift away from the philosophic
origins of science, each era had individual scholars who moved comfortably between
multiple seemingly opposing fields. Leonardo da Vinci (1452–1519) was one. Painter,
sculptor, musician, architect, anatomist, geologist, botanist, author, he delved into
everything from philosophy to mathematics, from warfare to aviation, a field not
yet invented in his day. The man who painted Mona Lisa wrote about the nervous
system: “The frog instantly dies when the spinal cord is pierced. Previous to this it
lived without a head, without a heart, or any bowels or intestines or skin. And here,

1 From John Stone’s “Gaudeamus Igitur: A Valediction.”

prefa c e: arts , s c ie n c e , a n d t h e p u r s u it o f k n o w l e d ge xiii

 therefore, it would seem lies the foundation of movement and life.” Leonardo
believed that it was necessary to master the body’s depths to portray its surfaces and
professed that painting is a science: “For painting is born of nature, since all visible
things were brought forth by nature and these, her children have given birth to
painting.”
While accomplishment in all disciplines is the gift of genius, the paths to knowl-
edge in individual fields are more egalitarian and accessible. And, fueled by the
imagination, compelled by a desire for order, empowered by the ability to see and
instinctively recognize the quest for knowledge in any discipline employs certain
common elements: observation, recording, perspective. And in science or the arts,
multiple perspectives, added dimensions, and adventures in time and space
abound.
Part of the brief but brilliant movement known as Renaissance in the North,
which included Albert Dürer and Mathias Grünewald, Hans Holbein the Younger
was able to grasp and depict the human image in a way that eluded his contempo-
raries. He was a deliberate observer. In his Nicholas Kratzer (Detail), 1528 (Figure 4),
it is easy to see how the painter sorted the evidence of physical reality fastidiously
gathered for internal character clues. In his portraits, the stubble on the chin or
smudge on the thumb was intentional, and the painstaking collection of minute
and precise detail built a composite larger than its parts. This intricate composite,
much often missed by the casual eye, was purposeful and focused. Free of extra-
neous or distracting elements, it dispassionately laid out for the viewer a meticu-
lous image to probe for inner meaning and interpretation. Selectively descriptive,
proportional, fully cognizant of order and balance, his portraits offered a glimpse
into a person’s soul and an unadulterated version of the artist’s perception of reality.
Observation is equally the domain of science. Fueled by the desire to know, it
drives systematic collection of data, the facts needed to formulate a unified concept
of nature and the laws that govern it. Scientific observation, like Holbein’s artistic
equivalent, goes beyond the chaotic collection of facts. Sufficiently ascertained and
methodically arranged and analyzed, facts form mathematical models create mea-
surable indicators, predict impact, and calculate costs to produce meaningful and
applicable public health models. John Snow’s meticulous geospacial maps of cases
during the 1854 cholera outbreak in London led to our understanding of the epide-
miology of cholera well before its cause was known and culminated in the iconic
removal of the Broad Street pump. When graced with clarity of expression, as in
Holbein’s portraits of distinguished humanists or John Snow’s geospatial maps,
observation produces good art and good science.
Intrigued by the similarities between the art and physics of the 20th century,
British professor Arthur I. Miller wrote Einstein, Picasso: Space, Time, and the Beauty
That Causes Havoc, a book in which he speculated a connection between the theory
of relativity and the modern art movement of cubism. A scientist turned historian-
philosopher, Miller investigated whether Einstein and Picasso were working on the
same problem, the nature of simultaneity. He found that relativity and cubism
were part of a cultural milieu within which both were focused on the nature of time
and space and the relation between perception and reality. The purpose of both
science and art, Miller noted, is to uncover the reality behind appearances.

xiv prefac e: arts , s ci en ce, a n d t h e p u r s u it o f k n owl e d ge

 “When our first encounter with some object surprises us and we find it novel or
very different from what we formerly knew or from what we supposed it ought to
be, this causes us to wonder and be astonished at it,” wrote 17th-century philoso-
pher René Descartes in his Passions of the Soul. Indeed, astonishment awaits any-
one who views for the first time the work of Giuseppe Arcimboldi, Milanese painter
extraordinaire, portraitist of emperors, and master of illusion.
Arcimboldi’s work has been ascribed to mannerism, the art of his times, known
for its aesthetic quality, exaggeration, and emphasis on emotion. But his creative
imagination moved in an entirely original direction. He turned elements from
nature or everyday life into images of his own invention, transforming fruits, vege-
tables, flowers, animals, or books into enigmatic portraits. The parts were known
and clearly understood, but the whole was new and elusive. For these elaborate il-
lusionist tricks or “hieroglyphic wit,” poet and theologian Gregorio Comanini called
Arcimboldi a “learned Egyptian.”
Arcimboldi’s Vertumnus (1590–1591), which graced one of the covers of Emerging
Infectious Diseases (Figure 5), was the most famous work of art in Emperor Rudolph
II’s Prague. In this portrait, the emperor was shown as the Roman god of seasons,
gardens, and plants, Vertumnus, who could change at will and was notorious for
his disguises. The portrait was eulogized and explicated in a poem by Comanini:
“Look at the apple and the peach— / Round, red, and fresh— / That form both
cheeks; / Turn your mind to my eyes— / One is a cherry, / The other a red mul-
berry.” Composite creatures have fascinated throughout the ages. Hellenic my-
thology proposed Chimera, which appeared on pottery 2,500 years ago and was
described by Homer in The Iliad as “a thing of immortal make, not human, lion-
fronted and snake behind, a goat in the middle, and snorting out of breath of the
terrible flame of bright fire.”
A tempting metaphor, Chimera has been adopted by many civilizations and,
more recently, by various disciplines, among them genetics, molecular biology, and
virology. Composites abound in nature. Those in the microbial world have gained
notoriety in the face of emerging disease, one that Arcimboldi would have delighted
in immortalizing. For this complex illusion, instead of fruits or flowers, he would
have portrayed MRSA, avian influenza (H5N1), E. coli O157: H7, and other hall-
marks of emergence: ordinary parts rearranged in a new context. Its specter would
have gone beyond astonishment to other common reactions evoked by the master’s
unpredictable work: unease and foreboding.
After almost two decades of publication, “a time probably between childhood
and adolescence in journal years,” as Founding Editor Joseph E. McDade put it,
Emerging Infectious Diseases has not strayed from its goal to communicate effec-
tively the undiminished potential for global emergence of infectious pathogens.
Under the enlightened leadership of D. Peter Drotman, physician and art lover, the
journal continues to track zoonotic diseases, bacterial pathogenesis, climate change,
the role of migratory birds in the spread of West Nile virus, infection in the health
care setting, bovine spongiform encephalopathy, the use of anthrax spores in bio-
terrorism; each theme, a new cover icon. The covers, and stories that accompany
them, have evolved, becoming more striking and substantive, thanks to the collab-
oration and generosity of artists, museums, art foundations, and galleries, who

prefa c e: arts , s c ie n c e , a n d t h e p u r s u it o f k n o w l e d ge xv
 have provided high-quality images and copyright permissions; the Emerging Infec-
tious Diseases journal team, who has maximized the effectiveness of cover images
and scrutinized the cover stories; authors, who brought to our attention works of
art from all over the world; and the many readers, who wrote to encourage our ef-
forts and urge that we continue to bring them the arts with the science.
“For you will learn to see most acutely out of / the corner of your eye / to hear best
with your inner ear.”2 How much meaning does cover art bring forth, and how much,
if at all, has the blending of the “two cultures” benefited understanding of public
health? Would Emerging Infectious Diseases be the same without the iconic covers?
The value added is not easily ascertained. Yet it would be prudent to continue making
the connections. For, as William Carlos Williams put it, “It is difficult / to get the
news from poems / yet men die miserably every day / for lack / of what is found
there.”
Polyxeni Potter
May 2013

Bibliography
Comanini G. The Figino, or, on the Purpose of Painting: Art Theory in the Late Renaissance.
Maiorino G, Doyle-Anderson A, trans. Toronto, Canada: University of Toronto Press;
2001.
Johns E. Winslow Homer: The Nature of Observation. Berkeley, CA: University of California
Press; 2002.
Kaufmann TDC. The Mastery of Nature: Aspects of Art, Science, and Humanism in the Renais-
sance. Princeton, NJ: Princeton University Press; 1993.
Potter P. Painting nature on the wing. Emerg Infect Dis. 2006;12:180–1.
Myrianthopoulos C. The philosophic origins of science and the evolution of the two cultures.
Emerg Infect Dis. 2000;6: 77–9. Available at: http://wwwnc.cdc.gov/eid/article/6/1/00-0115_
article.htm.
Seckel A. Masters of Deception. New York, NY: Sterling; 2004.

2 John Stone’s “Gaudeamus Igitur: A Valediction.”

xvi prefac e: arts , s ci en ce, a n d t h e p u r s u it o f k n owl e d ge

An Infected Heart; http://dx.doi. Avian Influenza; http://dx.doi.
org/10.3201/eid0707.AC0707 org/10.3201/eid1201.AC1201

Science, Public Health; http://dx.doi. Measurable Indicators; http://dx.doi.

org/10.3201/eid1203.AC1203 org/10.3201/eid1009.AC1009

Chimera of Infections; http://dx.doi.

org/10.3201/eid1411.AC1411
 Acknowledgments

T
his book would not have been possible without the support and enthusiasm
of D. Peter Drotman, Editor-in-Chief, Emerging Infectious Diseases; the collab-
oration and generosity of the CDC Foundation; Rima Khabbaz, Beth Bell,
Ted Pestorius, John O’Connor, Robert W. Pinner, and the National Center for
Emerging and Zoonotic Infectious Diseases; Joseph E. McDade, Founding Editor;
the late Joshua Lederberg, Robert Shope, and David J. Sencer; Frederick A. Murphy;
James M. Hughes; Ruth Berkelman; Anne Schuchat; Stephen M. Ostroff; Brian
W.J. Mahy; Kathleen Gensheimer; Pierre and Dominique Rollin; Charles Ben
Beard; David Bell; Nina Marano; Martin I. Meltzer; David Morens; J. Glenn Morris;
Didier Raoult; David Walker; J. Todd Weber; Kenneth C. Castro; Takeshi Kurata;
Charles H. Calisher; John E. McGowan; Robert Swanepoel; Stephen S. Morse; Scott
Halstead; David L. Heymann; Judith Aguilar; Nkuchia Mikanatha; Jackie Fox; Judy
Gantt; artists, museums, art foundations, and galleries that provided high-quality
images; authors, who brought to our attention works of art from all over the world;
the Emerging Infectious Diseases team: Reginald Tucker, P. Lynne Stockton, Carol
Snarey, Tom Gryczan, Anne Mather, Carrie Huntington, Sarah Gregory, Shannon
O’Connor, Claudia Chesley, Jean Jones, Karen Foster, Barbara Segal, Tracey Hodg-
es, and Kevin Burlison; CDC scientists and other experts, who provided guidance
and encouragement, among them Morris E. Potter, David Swerdlow, and Myron
Schultz; Louise Shaw, John Anderton, and Demetri Vacalis; and the many readers,
who wrote to encourage our efforts to bring them the arts with the science.

xviii
Disease Emergence

B
ritish naturalist Langdon W. Smith in his poem “A Tadpole and a Fish” (or
“Evolution,” 1909) traced events back to the Paleozoic era, the beginning
of life. “When you were a tadpole and I was a fish,” he told his true love,
putting their relationship in perspective, “My heart was rife with the joy of life /
for I loved you even then.” In his poetic account, Smith expressed eons of evolu-
tion, carefully marking landmark events as he went along. “We were Amphibians,
scaled and tailed / And drab as a dead man’s hand,” he noted, “Life by life, and love
by love, / We passed through the cycles strange, / And breath by breath, and death
by death, / We followed the chain of change.” This evolutionary change, so well
traced by Smith, is a major factor in the emergence of infections (Fig. T1.1).
The forces that shape emergence are diverse and in constant flux. They come
from all areas of life and involve all three aspects of the traditional triangle model
of disease causation: host, environment, agent. The forces that promote emergence
are therefore genetic and biological, environmental, social, political, and economic.
Their convergence supports disease emergence through many factors: microbial
adaptation and change; climate, weather, and ecosystems; economic development
and land use; human demographics and behavior; technology, industry, travel, and
commerce; poverty; and conflict.
The following sections in this collection reflect on factors contributing to disease
emergence. Each section contains cover art of Emerging Infectious Diseases and es-
says about the art and how it relates to factors involved in emergence. The final
paragraphs in each essay discuss art and science, but the connection between them
is intended from the very beginning. It is threaded throughout the essay, by way of
the artist’s life, the period of the painting and its tensions, and the style of painting,
as any of these elements can make an effective connection.
Emergence is fueled by change. Most emerging infections are caused by patho-
gens present in the environment but brought out of obscurity and given a selective
advantage or the opportunity to infect new populations by changing conditions.
Pierre-Auguste Renoir’s Luncheon of the Boating Party opens the section because it
exemplifies this notion. Change drives the history of art, too. The impressionist
movement, in which Renoir flourished, was a stylistic turn away from academic
tradition. It brought artists out of the studio, into the outdoors, to capture an im-
pression, a moment—all that one could ever hope to capture on the canvas.
Other factors in emergence—the way microbes and humans behave, complex
interactions in nature, and even developments in biomedical research—can and do
feature in the arts. Archibald J. Motley, Jr’s Nightlife provides the opportunity to

1
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