anthrax [88]. In 1969, most Americans breathed easier after President Nixon terminated the weapons program, and in 1972, he signed the Biological and Toxin Weapons Convention agreement. Despite this interdiction, in 1973 the Soviet Union began operating a gigantic biological warfare research project called Biopreparat, employing over 50,000 people in several centers. Naturally, there were casualties. In the early 1970s, 3 of ten people infected with smallpox died in a Soviet biological warfare accident, and in 1979 a large outbreak of anthrax occurred following a mishap in another bioweapons factory; in this instance 66 people and numerous animals died [89]. Biological warfare research still goes on, but deeply clandestine and illegal, and poses a major threat to the US from ISIS (Islamic State of Iraq and Syria) and other terrorist groups.
Since WWII
Unfortunately, the end of WWII did not end the ongoing warfare: at last count since then, “there have been some 250 major wars” [90]. Estimates of casualties vary considerably, from 23 million to over 50 million, including both military and civilian, with more of the latter than the former plus an increasing percentage of children compared with soldiers. America is still engaged in its longest war ever – in Afghanistan – 16 years and not over yet.
Consider the period from 2011 until 2016, it appears as though the world might be beginning to pacify: wars no longer occur in over half the earth: North and South America, Europe, and Australia (Antarctica does not count). Nevertheless, civil wars remain plentiful within Asia (Middle East) and Africa, including in Iraq, Syria, Libya, and Sudan. Lesser intranational military insurgencies in Africa have involved Somalia, Mali, and other locations. The only sovereign nations still engaged in recurrent warfare are Pakistan and India (Asia).
This last word comes from the ongoing horrendous war in Syria, which metamorphosed in 2011 from peaceful demonstrations to the formation of separate rebel forces, later supplemented by units from ISIS, illustrates once again how war ignites TB that may rapidly spread to neighboring countries. From 18 March 2011 to 21 January 2015, 78,769 civilian deaths occurred in Syria, of which 77,646 took place under control of non-state armed groups compared with 1,123 in government-controlled regions [91]. Between 2010 and 2014, life expectancy of Syrians decreased 20 years. In some regions 90% of the medical and nursing staff have left; medicines of all sorts and routine medical supplies have vanished. In 2011, the prevalence of TB in Syria was 23/100,000, today in 2017 it has soared to an unknown value. Anti-TB facilities have closed and medications are no longer available. Studies of Syrian refugees in Jordan have shown a nearly 40% greater TB case detection compared with the 2012 Jordanian rate [92]. Moreover, in Lebanon, a 27% increase in TB has been identified in Syrian refugees [93]. Given the increased exposure to TB, additional injured patients, health-care workers, and other uninfected personnel are likely candidates for the disease; few cases of drug resistance are currently known but others are sure to follow.
Conclusion
This opening chapter started with an historical evolution of hominids and their multiple prehuman and near-human predecessors, beginning millions of years ago. Our direct descendants, H. sapiens originated toward the end of the Pleistocene epoch, roughly 200,000 years ago. Resolving ice-age obstacles finally allowed early human migration to begin around 70,000 years ago, just when humans are believed to have become infected with human and other strains of MTBC. Migrants carried M. tuberculosis and spread it in its chronic form until about the 17th century in England and Wales, when it took advantage of the rapidly growing population, especially in London, to become a rapidly spreading crowd disease. No one is sure when, except that it was before the advent of written language and sometime during the switch from the nomadic habits of hunter-gatherers to a settled life of farming and domesticating animals. The early years of “civilization” were accompanied by war: including the formation of armies, improvements in weapons, and the development of military strategies. TB – the largest cause of death from disease during the 17th through 20th centuries – joined forces with warfare during WWI, and as detailed in the remainder of this book, during WWII.
TB and warfare are accidental partners, not kindred spirits. When they coexist, as in WWI and WWII and later conflicts, war seems to go its separate way: certainly, the destruction of industry, infrastructure, homes and property, and including casualties, both dead and wounded, have a raison d’etre all their own. But then that inevitable 70,000-year-old microorganism, M. tuberculosis, sneaks in and profoundly worsens the human misery and grief associated with warfare. Vulnerable people already harboring latent TB infection, trapped by the debilitating effects of war-induced semi-starvation, suffering from mental and physical stress, and needing treatment for diabetes, heart disease and other illnesses are likely “to break down” and develop active TB. Every step in the chain of spread of TB – beginning with an innocent uninfected bystander to a victim of fatal disease – is greatly exacerbated by warfare.
Thanks to the development of powerful new anti-TB medications and the availability of strengthened and more efficient case finding and infection control methods, victory now seems a real but distant possibility in the 70,000-year-old battle against TB. By contrast, it seems increasingly impossible that war will ever be silenced, and that warfare will continue killing millions of men, women, and children every year. It probably no longer matters whether or not humans are genetically programmed for killing each other, because warfare has become such a constant component of daily life. Nine countries possess over 15,000 nuclear weapons, but the distribution of warheads varies greatly among various nations: the US and Russia top the list. Strong efforts to ban nuclear weapons have been put forth, but no single country is ready to give them up, cheating remains an obvious problem, and at least India, Pakistan, and North Korea are creating them as fast as resources allow. Sooner or later, some rouge nation or terrorist group is likely to explode a nuclear weapon: what, then, happens next?
Acknowledgement
The author gratefully acknowledges the major contributions of Dr. Midori Kato-Maeda of the Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA.
References
1Johanson DC, Edey M: Lucy: The Beginnings of Humankind. New York, Simon and Shuster, 1981.
2Leakey M: Olduvai Gorge: My Search for Early Man, 1979.
3Leakey LSB, Tobias PV, Napier JR: A new species of the genus Homo from Olduvai Gorge. Nature 1964;202:7–9.
4Anton SC: Natural history of Homo erectus. AM J Phys Anthropol 2003;suppl 37:126–170.
5Klein RG: Paleoanthropology. Whither the Neanderthals? Science 2003;299:1525–1527.
6Trinkaus E: Pathology and the posture of the La Chapelle-aux-Saints Neandertal. Am J Physical Anthropol 1985;67:19–41.
7Richter D, Grün R, Joannes-Boyau R, et al: The age of hominin fossils from Jebel Inhoud, Marocco and the origins of the Middle Stone Age. Nature 2017;546:293–296.
8Henn