“What causes disease?” is a question that has been debated for a long time. The iteration of the debate that took place in late nineteenth-century France is worth revisiting today, as the global burden of disease continues to shift from communic able to non-communicable in nature. On one side of the scientific debate was the eventual winner, chemist and micro biologist Louis Pasteur. On the other side was Antoine Béchamp, a prominent physician and scientist. In its simplest articulation, their debate concerned whether to assign the bulk of the blame for disease to an external organism entering the body (Pasteur’s push for a “germ the ory”) or to the deterioration of the host’s body that allowed the external organism to cause damage (Béchamp’s focus on a theory of “fertile ground” or “terrain”). While there are complementarities, the differences between their positions have had considerable implications. Pasteur’s eventual success resulted in the prominence of germ theory, which has had a profound impact on subsequent developments in medical research, public health, and clinical care. Germ theory implies—correctly in many cases and for many diseases—that medical research should focus on pre venting the impact of a pathogen on the body. This has been achieved through the creation of many vaccines and by developing treatments (usually medicines) for when preven tion fails. In public health, germ theory led to a focus on erecting barriers to stop pathogens from getting access to the body. This has driven a range of strategies, including vector control (such as impregnated bed-nets for malaria), and promoting behavior change (such as abstinence or use of condoms for sexually transmitted diseases). In clinical care, the impact of germ theory is less clear cut. However, it could be argued that germ theory resulted in medical specialization and the focus on curative medicines and procedures. As a result, neither medicine nor public health have effectively tackled many long-term behavioral and environmental drivers of dis ease, as would have been implied by applying terrain theory.

SO, WHO WAS RIGHT?

At the time of the debate, over 140 years ago, there was significant evidence to support Pasteur’s side of the debate. The dominance of communicable diseases and high rates of child mortality both gave credence to germ theory over terrain theory. As a consequence of focusing on germs, the global health community has achieved amazing successes by developing life-saving vaccines and treatments that have played substantial roles in lowering infant and child mortality rates and increasing human life expectancy. Nevertheless, we also know that vaccines, medicines, barrier approaches, and clinical care do not effectively address all diseases. The failures (for both some commu nicable and most non-communicable diseases) should bring our attention back to Béchamp’s fertile ground the ory. For example, despite the existence of a highly effective treatment, many health systems have failed to effectively control tuberculosis.1 More recently, we have witnessed the disastrous impact of COVID-19 among people with meta bolic diseases. Finally, most non-communicable diseases fit the fertile ground approach.2–4 It is interesting to consider what would be different now if Béchamp had been more effective in pushing under standing of the fertile ground (the body). How might the fields of medical research, public health, and clinical med icine have developed differently? Much more importantly, now that we recognize that most of the dominant diseases of our age (as opposed to the nineteenth century) are non communicable in nature, how should medical research, public health, and clinical medicine adapt?

A THOUGHT EXPERIMENT

For a concrete thought experiment, let us focus on one specific non-communicable disease: type 2 diabetes. For most people with type 2 diabetes, the disease is not driven by an external pathogen. Instead, it is driven by the genetic predisposition, the available food environment, stress levels, sleep adequacy, and limited physical activity. Furthermore, people with type 2 diabetes frequently suffer from a precursor (hyperinsulinemia and insulin resistance) for up to 20 years before they are diagnosed with high blood glucose. Thus, damage to the body builds up for a long time prior to any medical attention or intervention. Given the pathophysiology of type 2 diabetes, how would a Béchamp-style approach reorient our approaches to tack ling this globally growing disease?

Medical Research

Béchamp-inspired approach to medical research on type 2 diabetes would put more emphasis and resources into addressing the medium- and long-term factors that affect lifestyles and the food environment. In contrast to the current approach, which peddles medical interventions to treat diabetes once it is diagnosed, the lifestyle/environ mental approach does not result in selling new products. Therefore, is not likely to be funded or promoted by the pharmaceutical and medical industries. Nevertheless, insurers and public funders of health care ought to see how their constituents—and therefore they—could gain from the terrain approach.

Public Health

Here again, a Béchamp-inspired approach would encou rage a long-term focus on addressing the environmental and behavioral drivers of type 2 diabetes. Refocusing resources and attention on behaviors and environmental  drivers requires multi-sectoral actions. This would mean revisiting how current tax and subsidy policies affect the availability of healthy foods and how food additives are regulated. It would also mean proactively tracking upstream risk factors, like hyperinsulinemia and insulin resistance, rather than waiting until a patient is hypergly cemic. This would require creating better assessment tools and implementing earlier screening and intervention.

Clinical Care

The longer time scale of non-communicable diseases (years) versus communicable diseases (days or weeks) means that a Béchamp-inspired approach would push medical practice toward earlier and more aggressive risk detection and prevention. Compared to current screening practices for type 2 diabetes, a more aggressive approach to detection could include creating better incentives for pri mary care providers to screen for risk factors of diabetes and hyperinsulinemia (such as family history, waist-for height, high triglycerides, low HDL cholesterol, high blood pressure, and skin-related issues) and more frequent insu lin focused testing (HOMA-IR or Kraft test). Changing the orientation of medical research, public health, and/or clinical practice is not easy, particularly given the momentum created by the primacy of germ theory for over 140 years. The financial interests of com panies invested in selling unhealthy foods and medical treatments raise even higher hurdles. But human beings have collectively achieved amazing things and changed our understanding of the universe before, as Pasteur did. Perhaps health care funders (government and insurers) and civil society groups concerned about the emerging cala mity of a generalized epidemic of type 2 diabetes (and other non-communicable diseases) will be able to build upon the messages pioneered by Béchamp to bend current practices toward a healthier and more sensible future.

Acknowledgments

The author wishes to thank Ms. Anya Guyer for the editorial work that substantially improved the clarity and style of the

Disclosure Statement

No potential conflict of interest was reported by the author(s).

References

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2. Lima-Martínez MM, Carrera Boada C, Madera-Silva MD, Marín W, Contreras M. COVID-19 and diabetes: a bidirectional relationship. Clínica e Investigación en Arterioscler (Engl Ed). 2021 May;33(3):151–57. doi:10. 1016/j.artere.2021.04.004 .

3. Cefalu WT, Rodgers GP. COVID-19 and metabolic diseases: a heightened awareness of health inequities and a renewed focus for research priorities. Cell Metab.2021 Mar 2;33(3):473–78. doi:10.1016/j.cmet. 2021.02.006 .

4. Le Roux CW. COVID-19 alters thinking and manage ment in metabolic diseases. Nat Rev Endocrinol. 2021 Feb;17(2):71–72. doi:10.1038/s41574-020-00449-y. Abdo S. Yazbeck Lead Economist and Adjunct Faculty, Johns Hopkins University, Baltimore, USA 该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。 http://orcid.org/0000-0001-7291-8783