At the close of the twentieth century, medical science could look back with a great deal of satisfaction on many outstanding achievements and successes in the control of communicable diseases. Confidence in controlling the bulk of communicable disease threats rose with the availability and effectiveness of an increasing number of preventive vaccines and therapeutic advances.

However, as the century was coming to a close there arose one of the most menacing of communicable diseases. This relentless plague, which would progressively and inexorably expand its reach into the human population, was HIV/AIDS. By the end of the century, South Africa came to carry the heaviest burden of the pandemic, with the largest number of people living with the infection in the world and driving the largest HIV/AIDS treatment programme globally. Close to one in five adults (15 to 49 years of age) are infected with the virus. The figure is even more frightening in some sections of the population, especially young women in KwaZulu-Natal, where the prevalence of infection is as high as one in three.

Some 40 years after the discovery of the virus the cumulative global death toll from HIV/AIDS, as of the end of 2021, stood at 40.1 million.

Given South Africa's disease burden, it is not surprising, therefore, that the HIV/AIDS research unit is the largest research unit in the NICD. It has contributed enormously to the understanding of the virus and the disease, as well as making important contributions to research efforts into developing the elusive protective vaccine. Unfortunately, political interference, yet again, had a turn in meddling in the activities of this unit, and in so doing wasted valuable resources, energy and time while the epidemic was advancing rapidly in the population. Support for dissident anti-science was fortunately temporary, but at the time it became a worrying reputational embarrassment.

THE EARLY DAYS OF THE PANDEMIC

The saga of HIV/AIDS commenced rather unobtrusively in Los Angeles in the autumn of 1980. An alert physician, Michael Gottlieb, and his colleagues were intrigued by the unusual presentation of a cluster of five young male patients under their care who were all diagnosed with a very uncommon form of pneumonia due to a parasite called Pneumocystis carinii. Previously, this infection had been seen almost exclusively in patients whose immune systems had been severely depressed, either by disease or drugs used in transplant recipients or patients on cancer therapy.

Unseen enemies – germs invisible to the naked eye and viruses invisible even under the light microscope – have ravaged humankind since prehistoric days. The fight against them is waged on many fronts. Most visible is the family doctor prescribing antibiotics for Grandad's bronchitis. Largely invisible to the general public, however, are the public health institutions combating the invisible enemy behind the scenes. This work means that no one today wakes up saying, ‘Thank goodness I don't have smallpox this morning’. This is the story of one such public health institution – the National Institute for Communicable Diseases (NICD) of South Africa.

Before recorded history there was already evidence of tuberculosis (TB) in the bones of prehistoric humans. The dreaded smallpox, a disease of great antiquity, was known to the ancient civilisations of China and India some twelve thousand years ago. The ancient Hindi civilisations in India even had their own special smallpox deity – the Shri Sitala Devi. Clear evidence of the scourge is visible in the mummified head of Pharaoh Ramses V, 1160 BCE. Centuries later smallpox was to bring death and misery to the royalty of Europe, to world leaders of several countries of Europe and North America, and to millions of the common people throughout the world.

Similarly, the Justinian plague, during the reign of Emperor Justinian I (527–565 CE), killed millions and was a portent of the Black Death catastrophe that swept through Europe some eight centuries later (1346–1352), and was estimated to have wiped out about one-third or more of the population of Europe.

These are but two examples of massive epidemics of communicable diseases, which continued to devastate human populations right up until the twentieth century. Between February 1918 and April 1920, three waves of the devastating Spanish influenza pandemic killed between 25 and 50 million people, considerably more than had died from the hostilities of the preceding Great War.

It is nearing a half-century since our vaccines eradicated smallpox from the planet; we are closing in on doing the same for polio and perhaps a few other communicable diseases. Modern medicine, advanced science and state-of-the-art technologies now appear to be able to deal pretty adequately with the communicable disease afflictions of yesteryear. But have we reached a stage, with the scientific armoury at our disposal, to be able to relax our vigilance? Are we done with communicable diseases?

With the possible exception of the provision of clean water, no public health intervention has had a more profound effect on reducing sickness and death than vaccination. It is impossible to calculate, and difficult to estimate, the number of lives that have been saved by the routine administration of vaccines. The WHO has provided an estimate of four to five million deaths prevented each year because of vaccines.

Another example of the power of vaccines comes from US data, showing that the number of cases and the number of deaths from the 10 most-feared epidemic and pandemic communicable diseases have been reduced by 96 to 100 per cent.The picture is similar in all Western countries that have similar excellent public health systems.

A GOAL WITH THREE PHASES

The goal of overcoming communicable diseases – for example, through vaccination – can be divided into three progressively ambitious phases: control, elimination and eradication.

Phase 1: Control

At the control stage, diseases have been successfully reduced in frequency to a low level; they are still present in the region or country but do not constitute a significant burden on the healthcare of the population. Control measures do still need to be in place to maintain that low level of disease. These measures include the continuing maintenance of the effective intervention which, in the case of vaccines, means achieving and retaining high levels of vaccine coverage. Importantly, competent monitoring is required to ensure that the disease continues to remain under control. Many vaccine-preventable diseases such as measles, whooping cough and diphtheria would fall into this category in South Africa.

Phase 2: Elimination

The elimination of a disease is defined by the total absence of that disease and the infective agent, in a region or a country, as a result of deliberate, active intervention. Protective measures are essential to ensure that the infective agent is not reintroduced from outside or re-established from any hidden internal source. In addition, to provide confidence and assurance that the infective agent is not present in that region, robust surveillance and monitoring programmes are crucial. Further, vaccination coverage needs to be maintained at a high level to ensure that the population's immunity remains sufficiently protective. In South Africa, polio would fall into this category.

Professionals in the medical field understand quite clearly what is meant by the terms ‘epidemiology’ and ‘surveillance’, but usually have difficulty in defining them. Practically speaking, these two terms can be usefully employed to describe the role of the NICD to provide data and information on the status of communicable diseases in the country. This is the bread-and-butter occupation of a public health institution like the NICD. Its activities cover the wide array of infectious agents: viral, bacterial, fungal and parasitic. This information and data are crucial for guiding public health authorities, nationally and internationally, and informing both the medical profession and the general public.

Some 60 years ago Alexander D. Langmuir, widely regarded as the father of modern communicable diseases surveillance and epidemiology, defined what is encompassed by the discipline of disease surveillance:

More recently, the pandemic of Covid-19, the ongoing threat of viral haemorrhagic fevers and the burden of HIV/AIDS and TB have underlined the critical value of a well-run, scientifically informed surveillance programme. The success of communicable diseases surveillance, as is the case with surveillance for exposure to noxious chemicals, is crucially dependent on the timeliness of being alerted to the earliest signals of an impending outbreak. For example, surveillance of wastewater to detect the circulation of pathogenic organisms, such as SARS-CoV-2, or surveillance of acute flaccid paralysis (AFP) (the typical clinical sign of polio), have been shown to be effective tools for the early detection of impending outbreaks. Prompt responses to effect control measures need to be initiated as early as possible before an outbreak erupts in a population.

The fight against the invisible enemy is still very much with us. Many battles have surely been won and countless lives have been saved through scientific progress. Life expectancy globally has gone from 58.6 years a hundred years ago to 79.3 years today. This has been due to a combination of improvements in food supply, provision of clean water, healthier lifestyles and, of course, enormous gains in preventive and curative healthcare, including advances in controlling communicable diseases. However, much still needs to be done, especially in the developing world and in deprived communities.

How far can humankind go in its battle against the unseen enemy of viruses and microbes? The enemy cannot be totally vanquished, and substantial challenges remain. One daunting challenge for contemporary healthcare workers in the third decade of the twenty-first century is the scourge of multi-resistant bacterial infections resulting from overuse or abuse of the antibiotics designed to treat these infections. In battle parlance, the term is ‘friendly fire’. After decades of research, effective vaccines against HIV/AIDS and TB still need to be designed, produced and distributed to where the need is greatest. And humankind remains vulnerable to new infectious diseases introduced from animal sources.

However, coming out of the recent Covid-19 pandemic and looking back at our responses to many other epidemics and communicable disease outbreaks, we can take home several valuable lessons. What is now abundantly clear is that the fight against the unseen enemy must be fought on a considerably broader front than only discovering and producing new and effective antimicrobial drugs and vaccines. The war has to be contested on a more holistic battlefront. Winning will only come if all three contributions to the battle are given equal urgency: (1) the scientific contribution, to provide the necessary advanced resources; (2) the general public's contribution, to support implementation; and (3) the politico-economic contribution, for the necessary material resources.

1. THE SCIENTIFIC CONTRIBUTION

The empirical vaccines of the twentieth century demonstrated spectacular success in eradicating smallpox and eliminating several childhood communicable diseases from large swathes of the planet.

I have had the personal privilege, honour and pleasure of serving in the National Institute for Communicable Diseases (NICD) and its predecessor institutes – the South African Institute for Medical Research (SAIMR) and the National Insitute for Virology (NIV) – for close to four decades. After my involvement in creating the NICD and serving as its founding director, I retired from the institute and have watched it grow to its illustrious present.

As 2019 was coming to a close Covid-19 arrived, the most serious pandemic to afflict humankind since the devastating Spanish influenza of 1918/1919. Covid-19 ignited unprecedented interest in public health and especially as it pertains to communicable diseases. The NICD was at the forefront of informing the public and guiding the authorities during the pandemic.

It seems that there is broad interest in hearing the story of the NICD. A goodly number of my professional colleagues, past and present, as well as non-professional friends, have urged me to tell the story of this venerable institution. Colleagues in the fields of communicable diseases and public health have been curious to learn about the origins of the institute and what went into its development, its colourful history and the rocky road of the early days. Many of my clinical colleagues have been keen to understand what lies behind the advisories, the bulletins and the research emanating from the institute. During Covid-19, but also for many years in the past, the NICD has occupied a prominent position through various reports in the media generating widespread and extensive interest from the non-professional but informed public. I would venture that a number of good citizens driving past the gates of the institute on Modderfontein Road on the north-eastern outskirts of Johannesburg wonder what exactly lies on the other side of the fence, and what goes on behind the scenes in those buildings. It was to provide answers to this broad spectrum of interests that inspired me to write this book.

The Andromeda Strain (1969), Outbreak (1995), Pandemic (2020) and several other books and movies have captured the public's fascination with and fear of deadly infectious agents. The combination of high fever with copious production of blood and a rapidly fatal infectious disease are the essential ingredients of horror science fiction. However, they came to real-life reality with the advent of the feared and formidable viral haemorrhagic fevers.

The African viral haemorrhagic fevers, the most formidable of all, with mortalities approaching 90 per cent, sowed considerable alarm and fear in South Africa when some cases were sporadically imported into Johannesburg. It was the initial imported case in 1975 that triggered the establishment of the NIV. The highly specialised maximum-security laboratory, the only one on the continent, soon became a world leader in handling and investigating these viruses. The staff of the Special Pathogens Unit (SPU) have ventured into some of the most inhospitable places on earth to help control outbreaks of the disease and have significantly advanced research into these frightening infectious agents.

THE AFRICAN HAEMORRHAGIC FEVER THREAT

The first alarm bell

The drama of the first viral haemorrhagic fever on South African soil began rather quaintly – at a dinner party in February 1975. Professor James Gear was hosting the associate director of the Rockefeller Foundation for dinner at his home. The party was about to sit down to dinner when Gear's son, Dr John Gear, a consultant physician at the Johannesburg Hospital, arrived at the house, still in hospital scrubs and greatly worried about a patient in his care. The patient was a 20-year-old Australian man who presented with a high fever, a very sore throat, vomiting blood and bleeding from needle puncture wounds. That put an end to the dinner party with Gear and his guest hurrying to the hospital to examine the patient.

The man and his female companion had hitchhiked through Zimbabwe, sleeping on occasion out in the open and coming into contact with monkeys and a civet cat. Despite intensive treatment, the young man died a few days after admission. His companion soon became gravely ill with a similar presentation but survived, as did the attending nursing sister looking after them who subsequently also became infected.

The honoured parents who gave birth to the NICD were two venerable public health institutions. First came the esteemed South African Institute for Medical Research (SAIMR), and second, an equally esteemed but younger institution, the Poliomyelitis Research Foundation (PRF). Very soon after their individual births both institutions found themselves accountable for vastly more than their single disease responsibilities, pneumonia in the case of the former and poliomyelitis in the case of the latter.

With the SAIMR it was the wide spectrum of laboratory medicine, and with the PRF the wide array of viral diseases of humans.

THE SAIMR (1912–1999)

In 1912, just two years before the start of the First World War, the Chamber of Mines of South Africa, the employer organisation of the country's mining industry, provided funds for the creation of the SAIMR. Its mission was to carry out research into the various medical challenges facing the mining industry, most specifically pneumonia. The government of the day provided an equal amount of funding for the institute to be a facility to serve the population of the country as a whole.

Not long after the birth of the SAIMR, the First World War broke out and the institute was called on to provide medical support for the war effort. With the outbreak of the Second World War in 1939, the institute was again called on to provide medical support for the war effort. This saw a much greater demand on the institute. Supplies of yellow fever and typhus vaccines went north to the military and civilian populations of the African continent involved in the conflict, and the typhus vaccine was sent to the Soviet theatre of the war.

In the earliest days of the SAIMR, the needs of the mining industry ensured that a great deal of energy went into research on bacterial pneumonia, a huge problem among mining personnel at the time. The causative bacterium, the pneumococcus, was rigorously investigated, leading to the development of an effective preventive vaccine. This achievement earned a knighthood for the second director of the SAIMR, Sir Spencer Lister. Research in bacteriology expanded rapidly in the ensuing years, with significant findings being published on a variety of bacteria such as typhoid fever, whooping cough and plague.

By the mid 1970s the responsibility and financial burden of maintaining the rapidly expanding laboratories of the PRF was becoming too much of a burden for the board of trustees and approaches were made to the Department of Health to purchase the laboratories and take over their governance. The timing of the negotiations, which led to the official establishment of the NIV, was good for both sides. For the board it was monetary as they were unable to continue funding the research labs, especially as medical virology, with its attendant burgeoning costs, was a rapidly expanding field.

From the government's side a major public health concern was causing some alarm. This was the looming threat of viral haemorrhagic fevers and the related newly recognised formidable infectious diseases that were appearing on the African continent. The risk of importing exotic viral infections into the country, particularly from elsewhere in Africa, preoccupied government minds, especially as large numbers of migrant workers from Southern, south-eastern and Central Africa were employed in South African mines. It was clear that there was an urgent need to establish an institute of public health excellence in viral infections.

An agreement was reached, which saw the Department of Health purchasing the viral research component of the PRF, its site and the buildings – which would become the future NICD – for the sum of R1.3 million. The NIV duly came into being on 1 April 1976. Whoever chose that date was probably oblivious to the humorous side of that choice. While the move was necessary and timely, the shift into a government office was a serious mistake. The petty civil service rules and restrictions that came with the move greatly encumbered the functioning of the new institute. To make matters worse, South Africa had become a pariah state in the apartheid years and the accompanying international ostracism further handicapped the development of the NIV as a scientific institution.

From the Department of Health's perspective, their concerns had not been unfounded. These were quite dramatically brought to a head in early 1975 when the first recognised viral haemorrhagic fever case in South Africa was recorded.

One of the earliest priorities of the new government of the country in 1994 was to remedy the past inequalities of healthcare delivery and also to provide much-needed institutional support for public health. The idea to create a national public health institution specifically for communicable diseases, which accounted for some 70 per cent of the health burden of sub-Saharan Africa, was first raised in 1995. Some six years later it was the establishment of the more broadly encompassing NHLS which finally enabled the creation of the NICD, in 2001. Again, meddlesome, unproductive political interference threw obstacles onto the pathway of its development.

The proposed new national health plan was contained in a document entitled ‘A National Health Plan for South Africa’ and was published in May 1994. The document set out a comprehensive health programme with the express goal of providing health benefits to all South Africans. The elements of the plan were directed at strengthening health systems over a broad spectrum of healthcare. In particular, there was a focus on redressing the past inequities of health delivery. This included the building of capacity in the health sector and improving the effectiveness and efficiency of all components of the health system for all sectors of the population. Laboratory services were singled out as being one component of healthcare delivery that needed to be remedied, as it was ‘plagued by gross fragmentation and duplication with serious disparities in laboratory service provision, especially along racial and geographic lines’. Not surprisingly, the national health plan included a section on laboratory services and called for the establishment of a national health laboratory service.

THE NATIONAL HEALTH LABORATORY SERVICE (NHLS)

Soon after April 1994, the newly appointed minister of health, Dr Nkosazana Zuma, appointed a task team under the chairmanship of Professor Jan van den Ende, previously director of the SAIMR and head of medical microbiology at the universities of the Free State and Natal, to address the challenge of establishing an effective and comprehensive national laboratory service for the country. The team was tasked with creating a plan to consolidate all public-sector medical laboratories. Following the release of the Van den Ende report, a project implementation team was created to put into effect the restructuring of the public health laboratory services of the country.