At the limits of medicine
At some point during those fateful days, microbes barged their way into Alfred Gertler’s life. They lodged themselves there, spread all over and took control. They devoured his bones.
Gertler, who was 41 at the time, had signed up for a gig on the cruise ship MS Maasdam for a few months. His lopsided house in Toronto was «full of my two sons’ diapers, but we were pretty short on money», as he put it. He hoped to remedy the situation by working as a musician on the ship.
In March 1996, the Maasdam was cruising in the Pacific along the shores of Central America. Gertler left the luxury liner during a stop in Caldera, Costa Rica to rest from his hard work as a bass player. It was intended to be a break from the gruelling daily concerts, which ended with the players up to their ankles in music because there wasn’t even enough time to turn pages. Yes, a hike in the hills at the end of the Pacific Ocean would do him good.
That’s not quite how it turned out. On the way back he lost sight of the footpath. Since the 4 o’clock rehearsal would begin shortly, Gertler decided to climb down the steep slope below the path down to the road. This decision would change his life forever.
It was a short fall, less than 15 ft. The root Gertler grabbed onto on his way down broke off. Suddenly he was lying on his back, completely unable to move. «My foot was folded like a sock», he recalls. «My bones were sticking out. They looked white and soft», he told me when I visited him in Toronto six years later.
Some local souvenir vendors strapped him to a board and carried him down to the city, where his foot was bandaged and put in makeshift splints and his wounds rinsed out. And all this without any anaesthesia. Gertler was afraid that if he had an injection, his foot might become infected. He was transported over a bumpy road to the hospital in San José, the capital. Six days later, he flew back to Toronto. His GP inspected his cast and decided to leave it at that.
At this point, the bacteria must have already sneaked into the wounds. The germs would cripple his foot, confine him to bed for years and expose the limits of medicine. Perhaps the microbes were lurking in the soil where he tumbled down the slope. Or maybe they were hiding in the mildewed bathroom in the San José hospital, which had filled Gertler with such utter panic that he had scrubbed the shower for two hours before setting foot in it. There’s no way to say for sure, since the bacteria silently ran rampant under the cast until the pain in Gertler’s swelling foot drove him to the hospital. Too late.
The orthopaedist at Sunnybrook Hospital made a shattering diagnosis: «If you don’t die, then your foot will.» Gertler was given an ultimatum: have his foot amputated or the bacteria would continue to eat their way up the bones, damaging first the foot, then the lower leg and then the thigh. Gertler panicked. He didn’t want to lose his foot.
Desperate, he dragged himself to another hospital. The doctors there agreed that his foot should be amputated. Gertler again refused to have the operation. That was the beginning of a battle between the doctors and the staphylococci – the germs commonly known as ‹staph› – in his ankle. They used the strongest medicine available. For more than two years, Gertler continuously received antibiotics. For a year, they were injected directly into his bloodstream via an electric pump.
These miracle drugs, which many people consider to be the greatest medical achievement of the 20th century, were a complete flop. The sustained attack of cloxacillin and ciprofloxacin, the drug made famous by the anthrax attacks in the US in autumn 2001, barely dented the microbes in Gertler’s foot. They hunkered down in the bone, gnawed away at it, kept the joint swollen for years and held open two gaping, weeping wounds.
Gertler spent most of the time in bed: «Even going to the pharmacy around the corner on my crutches and hobbling back was enough to make all hell break loose.» The movement in the broken joint ejected the microbes from their hiding places in the bone and the neighbouring tissue and sent them to the bloodstream, where they multiplied like crazy. The ensuing blood poisoning and the overreaction of the immune system connected with it – doctors refer to this life-threatening combination as ‹sepsis› – confined Gertler to bed for weeks with fever, chills and continuous fatigue.
«The worst thing was when the wounds healed up again», he told me, «because then the hope returned that it was all over. I finally got out of bed, played music and, whoosh, it broke out again.» He experienced this so often that you could hardly hear the bitter disappointment in his voice any more.
The strange thing was that, in a test, the microbes didn’t even show a particularly raised resistance to antibiotics. Antibiotic resistance is a nightmare for infectious disease specialists, who increasingly have to stand by and watch helplessly as bacteria dupe the drugs aimed at them and people die because no drugs work. Ironically, an estimated 10 per cent of all patients in hospitals are infected by bacteria. In the US alone that makes 2 million patients per year, and 90,000 of them die, 70 per cent from highly resistant bacteria.
In Gertler’s case, the antibiotics simply couldn’t reach the colonies of staphylococci in the bones: «I couldn’t believe it. I had an infection with staph – one of the most common complications of surgery – and not a thing could be done about it.»
Gertler was just one of many patients who suffer the same fate. Just because an antibiotic destroys the germs in a test tube doesn’t guarantee that it will pack the same punch in a patient’s body. The drugs are especially ineffective in places with a poor blood supply, like bones. Victims are constantly subjected to new operations to cut out affected tissue which disfigures them more and more.
For Gertler, doing gigs as a bass player was now out of the question. Money became tight. And being deprived of music – his passion – was just as bad. In his old house on Kensington Market in Toronto, whose esoteric shops, jazz cafés and vegetarian restaurants are reminiscent of hippy capital Haight- Ashbury in San Francisco, there are always lots of different radios in the different rooms all tuned to the same jazz station, even at night. «The infection was like a wish from hell. Hey – you want to sit in bed all day and listen to music? Okay, here it is.»
It got even worse. His wife moved out and took the two children with her. «I don’t blame her. It’s pretty hard to stand it with a guy who lies in bed all day, is tired all the time and constantly complains that he’s in pain», he told me as we sat sipping tea in his kitchen.
The corners and walls of Gertler’s house are full of pictures of his sons. On the doorframe you can still see the marks he used to record the boys’ heights as they grew. The last is at 89 cm. When Gertler sees it, he always thinks of what the doctor told him: «When your foot gets bigger than your life, get rid of it.»
Gertler’s foot is still attached. He started fighting, looking for ways to conquer the bugs and liberate his foot from the destructive staph. Since Gertler wasn’t internet savvy, his brothers and his parents helped him to search for information. As it turned out, it wasn’t the Web that helped the desperate musician. It was pure coincidence. In early 2000, nearly four years after his fateful accident, a friend of Gertler’s collapsed while riding his bike. The emergency doctors’ diagnosis was acute blood poisoning – caused by staph.
Gertler paid his friend a visit in the hospital. The 6 February 2000 issue of the New York Times Magazine was lying on his tray table. In it was an article about an amazing treatment from the Republic of Georgia. Gertler devoured the article, learning that in this distant land in the Caucasus, microbes were being used to fight microbes. The physicians there let special viruses loose on the bacteria. For each type of bacteria, nature provides a matching virus that decimates the pack with chilling efficiency, leaving humans unharmed.
The treatment operates on the principle: «My enemy’s enemy is my friend.» It was also used in the Western world well into the 1940s. Yet the success of the treatment varied widely and, with the discovery of penicillin, it was abandoned. In contrast, in the Soviet Union, therapy involving bacteriophages, as the tiny bacteria-exterminators are called, continued over the years – almost unnoticed by Western medicine.
In Gertler, the seeds of hope began to germinate. Especially intriguing was a bit in the feature describing how, in Georgia, the method was used to target cases in which antibiotics didn’t work. «That same evening I limped off and made ten copies of the article.»
At the very end of the text, it was reported that a bacteriophage conference was about to be held in Montreal, only 530 km from his home. Gertler contacted the organizer, Michael DuBow, a researcher at McGill University in Montreal. «DuBow told me that it was a scientific conference, but I could attend if I paid the registration fee.»
The conference was primarily dedicated to basic research on phages, which had also been carried out in the West. However, the growing crisis regarding resistance to antibiotics had sparked the interest of several biotech companies and scientists in phage therapy, so some lectures on this topic were scheduled too.
So here was Alfred Gertler, a jazz bassist, at his first scientific conference. Even among the crowd of scientists, who were otherwise oblivious to the outside world, he stuck out, with his crutches and his inevitable Greek fisherman’s cap. «In the breaks he hung around the smokers who would stand around outside on the steps», recalls Elizabeth Kutter, a phage researcher who later ended up helping Gertler.
It didn’t take long for him to get to know several scientists who were exploring phage therapy. Treating him, however, was something altogether different, too much of a risk for them. As a treatment that had not been sufficiently tested or approved, no one in Canada or the US was allowed to use it without risking serious consequences from the health authorities. «Despite this, though, there were a few scientists who offered to help me right away», Gertler said. «‹Bring us a bacteria sample from your wound›, they said, ‹and we’ll pick out the phages that will work in our lab.›»
On the final day of the conference, on a boat ride on the St Lawrence River, Gertler struck up a new acquaintance during a smoking break. «I asked the guy if I could have a puff. I don’t really smoke, but it restricts the circulation in my foot and helps me to get home without it hurting so much. And we got to talking.»
The chain-smoking researcher was from Georgia, the country featured in the New York Times Magazine article. «He asked me for a bacteria sample. I hobbled to the restroom. A storm was in progress and rocked the boat like crazy. I had to be really careful not to fall over as I was taking off my shoe and sock. I took one of the cotton swabs that I’d been carrying around with me the whole time during the conference, scraped off some secretion from the wound and put my sock and shoe back on again. Then I limped back on deck.»
The researcher gave Gertler his business card. It said: Revaz Adamia, Chairman of the Defence and Security Committee of the Georgian Parliament. «I thought he was from the KGB, and I’d never hear back from him again.» Yet soon after the encounter, Adamia, who worked full time as the head of a lab at the Eliava Institute for Bacteriophages, Microbiology and Virology, sent Gertler an email from the Georgian capital of Tbilisi: «We have the right phages. Treatment at the local hospital is no problem.»