For his grandchildren it was a discovery, and one, I thought, which might transform his relationship with them – but this calling-into-action was well known to his old friends in the community. Once a week, he would go to the senior center – he would have to be picked up and lifted (‘like a corpse,’ he said) into the car; but once there, and seated at a card table, he could play a fast and hard game of gin rummy. He could not start the play – someone else had to do this – but once the first card was slapped down, he would suddenly come to life, respond, pick up another card, and continue the game. The people of Umatac, Merizo, Dededo, and Santa Rita may have little scientific knowledge of parkinsonism, but they have a great deal of informal knowledge, a folk neurology based on decades of close observation of the bodig in their midst. They know well how to unfreeze or unlock patients if they get frozen, by initiating speech or action for them – this may require another person walking with the patient or the rhythmic pulse of music. They know how patterns on the floor or the ground can help the parkinsonian to organize his walking; how patients scarcely able to walk on a flat surface can negotiate complex obstacles, rough terrain, easily (and indeed, fare oddly well with these); how the mute and motionless parkinsonian can respond beautifully to music, singing and dancing, when speech and motion had previously seemed impossible.
But what was it that had caused the lytico-bodig, what was it that had come and gone? There had been a sort of conceptual vacuum, John said, when the cycad hypothesis had collapsed in the early seventies. The disease continued to claim more Chamorros, and patients were treated, when possible, for their symptoms – but there was a marked lull in research for a while, at least in Guam.
And yet in the seventies there was a discovery of great importance. Two pathologists, Frank Anderson and Leung Chen, performed autopsies on two hundred Chamorros, many of whom had died suddenly in traffic accidents. (Agana had been a small, slow-moving town before the war, and transport was leisurely – usually by carts pulled by the big-horned carabao, along the rutted and frequently flooded roads. But following the war, there was a sudden increase in population, especially American military, who brought along with them fast roads and cars; this caused a sudden rise in traffic fatalities among the Chamorros, who were wholly unused to this rapid pace.) None of these people had ever shown any neurological symptoms; yet seventy percent of those born before 1940 showed clear pathological changes in the nervous system similar to the neurofibrillary tangles which Hirano had found in patients with lytico-bodig. The occurrence of these neurofibrillary tangles fell off sharply in those born in the 1940s, and they were not seen at all in anyone born after 1952. This extraordinary finding suggested that the lytico-bodig might have been almost universal among the Chamorros at one time – even though only a small proportion went on to develop overt neurological symptoms. It suggested, moreover, that the risk of contracting the disease was now very much reduced – and that even though cases continued to occur, these had probably been contracted many years before, and were only now becoming symptomatic. ‘What we are now seeing, Oliver,’ said John, pounding the steering wheel for emphasis, ‘are the late effects of something that happened long ago.’[69]
When Yoshiro Yase, an ardent sport-fisherman as well as a neurologist, went to study the newly identified disease focus on the Kii Peninsula, he was told there were scarcely any fish in the local rivers, and this prompted him – memories of the Minamata tragedy still being vivid – to analyze their waters. Though these were free of infectious agents or toxins, they were oddly low in calcium and magnesium. Could this, he wondered, be the cause of the disease?
Gajdusek was fascinated by Yase’s findings, the more so as he had been struck by the red soil, rich in iron and bauxite, in the swamp lands around the Auyu and Jakai villages. When he was able to return in 1974 – Western New Guinea having become Irian Jaya in the intervening upheavals – he now tested the water from the shallow wells which the villagers dug in the red soil, and found unusually low levels of calcium and magnesium, as well as elevated levels of iron, aluminum, and other metals.
At this point, Kurland moved to the Mayo Clinic to pursue other research, feeling that the cycad hypothesis, though valid, could not be proven. His place at the NIH was taken by Gajdusek, who was now intrigued and excited at the notion of a mineral etiology of the Western Pacific disease. Gajdusek enlisted Yase, and together they examined well water from Guam and found that this too was low in calcium and magnesium. This triple coincidence seemed definitive:
Comparison of the Western New Guinea focus with the foci of ALS and Parkinson’s disease on Guam and the Kii Peninsula of Japan is inescapable [Gajdusek wrote], and the close association of parkinsonism and motor neuron symptoms in yet another non-Chamorro population group should not only dispel most doubts about the probably close relationship between the two syndromes, but also point to an aetiologic role of some unknown environmental factor.
The unknown environmental factor, it seemed likely, had to do with low calcium and magnesium levels in the drinking water, and the consequences of these on the nervous system. Such low levels, he speculated, might trigger a compensatory reaction in the parathyroid glands, leading in turn to excessive absorption of calcium, aluminum, and manganese ions. The deposition of these in the nervous system, he felt, might result in the premature neuronal aging and death seen with the lytico-bodig.
It was John’s hope, in 1983, that he might join Gajdusek’s team and help crack the disease at last. But Gajdusek told him he was too late – the cause of the lytico-bodig had now been established, and in any case the disease had almost vanished, because of the shift to a Western diet, which was high in calcium – there was not much left to do, and his team would be pulling out of there soon. John was surprised to hear Gajdusek express himself so forcefully, he told me, and disappointed, because he had hoped to work with him. But he decided to come to Guam nonetheless, if only to take care of patients as a physician, and not as an investigator.
But the very day after John arrived on Guam, he had an experience comparable to Zimmerman’s nearly forty years before: working in the naval hospital in Agana, he saw a dozen patients with the lytico-bodig in his first clinic. And one of them also had a supranuclear palsy – a complex disturbance of gaze, in which the patient can look sideways, but not up or down. This had never previously been reported in lytico-bodig, but it was the hallmark of the syndrome John and his Toronto colleagues had delineated nearly twenty years before. This convinced him that lytico-bodig was neither extinct nor comprehensively described, and that there was still time and opportunity for its further investigation.
Guam had superb medical facilities on the naval base, but in the outlying villages, basic medical care was very inadequate, and neurological care scarce – there was only one overworked neurologist, Dr. Kwang-Ming Chen, to care for 50,000 Chamor-ros, and 100,000 other residents of the island as well. Not only were there still many hundreds of Chamorro people with lytico-bodig, Chen told John, but new cases kept appearing – several dozen a year, he thought, and these new cases sometimes took forms different from either the classic lytico or bodig; the man with supranuclear palsy was a case in point.