Picture of Ken FlegelKen Flegel is senior editor, Research, at CMAJ; an internist at Royal Victoria Hospital; and a Professor of Medicine at McGill University in Montreal


Readers will have observed that any present state of the natural world appears to be the result of an encounter between a creative force and a destructive one. For purposes of this essay I ask readers of whatever religious persuasion, and of none, not to take offense if I employ a familiar literary device in referring to the author of the first force as Lord and of the second, as Devil. The setting is again a literary one (with due acknowledgement of C.S. Lewis and The Screwtape Letters). At the centre of the struggle is a unique human attribute: the ability to make thoughtful choices about matters in the future. Lastly, and most importantly, I beg persons who have suffered from the disease at issue not to be further wounded by any levity about it here – my purpose is a serious one.


“Gather ‘round me devil hearties,” called Devil. “The Lord has created the universe, formed the planets and set the earth in its orbit. Humans, and all the creatures in their charge, have multiplied and grown numerous. Despite all our efforts to persuade humans of our power to destroy, the Lord’s creation is flourishing.”

“Steady on,” countered devil 2nd-in-Command (henceforth 2iC). We’ve done pretty well; showed a lot of inventiveness. Destruction and havoc have generally ruled. We brought fires then floods, followed by volcanoes, earthquakes and tidal waves. Then just when life forms reached a spectacular variety and abundance, we swerved that great meteor into Mexico ejecting enough debris into the high atmosphere to bring on enduring winter and a massive dying out of life – not bad going that!”

“Yes, yes,” allowed Devil. “Big and impressive; but not subtle. And besides, the Lord did make the sun come out again raising up new forms of life which we now have aplenty once again.”

“So, that is when we invented war,” offered devil 2iC. “Remember our success at getting humans, the Lord’s finest creation, to set about killing one another? And now they carry on without much input from us, inventing ever more clever weapons to make sure that will be maimed or killed. We must have impressed some of them with our ability.”

“Yes, it has worked for quite a while,” said Devil. “But there are worrying developments these days. I hear more and more humans acknowledging that war only leads to more war. Most worrying of all to me is that some of their best writers have been examining the idea of human freedom. One or two have got so perilously close to the truth about it, it stops me from sleeping. Once they realize that human freedom is a collective value only—that is that no one person can enjoy true freedom as long as another person is not free—war as a destructive device will be finished. I think we need a new idea for causing destruction. We need something hidden from human senses, something subtle. Effective but subtle.”

“Well, Devil,” 2iC mused, “We have had this discussion over many thousands of years. The first time we became concerned about naked-eye detection, we turned to subverting the Lord’s magnificent creation of microbes. Remember plague and syphilis? Then tuberculosis, leprosy, cholera, typhus and malaria? How about those influenza pandemics? Humans have gotta be convinced by our record of causing suffering and death!” he boasted.

Devil stroked his chin. “A bit like that comet, don’t you think? They can discern that it is coming. With that wonderful mind the Lord has given them, humans learn to take aversive measures. We need something that is hidden by being so obvious they can’t recognize it with their complicated way of thinking. It would spread widely, invade and begin to destroy, slowly but massively, before anyone realizes what is happening. We should start with the most fragile and vulnerable of humans in order to delay recognition. The resulting suffering will surely cause humans to worship our powers!

“Well,” pondered 2iC, tugging at his ear lobe, “I think we are still talking about microbes. Let me see…remember when the Lord created anaerobic bacteria? We thought it was a neat trick but couldn’t see much purpose in them. True, they do assist in rotting dead animal and plant matter especially where there is no air. I remember thinking that they were creatures ripe for destructive use, but so far we haven’t been able to take real advantage of them.”

“Yes, yes,” recalled Devil. “I remember our first efforts with tetanus; now that’s a real killer. But it has proved difficult to get many wounds really dirty and keep them that way long enough. Besides, humans with their inventive minds have got that one on the wane with their vaccines. Same with the botulinus toxin and the use of proper food preservation. And our efforts at invasive clostridial cellulitis and gas gangrene were just too apparent to the naked eye- Dr. Welch was on to that one right away.”

“Maybe, just maybe,” rejoined 2iC “we could conceal a Clostridium in a place that human’s just don’t see. Then we could give it a toxin that enables it to invade deeply before anyone is aware.”

“That’s it!” cried Devil.

“What is?” asked 2iC.

“The human colon!” he replied excitedly. ”No oxygen. Can’t see inside.”

“OK…but what about all those antibiotics, most of which are swallowed?” wondered 2iC.

“First we insert all the resistance factors we have ever invented,” said Devil. “Then we can rely on antibiotics to create a nice vacuum in the normal colon where one third of the bulky contents are made up by bacteria. Our new Clostridium can fill the void!”

“And what about antiseptic chemicals, radiation and heat?” asked 2iC.

“Spores!” Devil exclaimed. “Spores that can resist chemicals and radiation and heat that human flesh cannot stand. They would never dream of trying any of them. Spores that can survive on household surfaces for decades.”

“And transmission?” persisted 2iC.

“Hands, my devil, human hands! Recall that the human colon is an organ of release and contentment when it is working well. Hands clean it up but who cleans the hands? When a human’s body is bent on release and contentment, it becomes difficult to turn the mind to an abstract idea like ‘hand hygiene’. We can rely on humans not to wash their hands well enough to remove the first layer of skin oils in which the spores will be stuck. And yet this will be the only effective way of preventing transmission (1). Don’t you see how beautifully simple and obvious it all is? Humans are far too sophisticated to spot something so easy to see. And as for their penchant for research, we will make it difficult to culture the microbe using ordinary techniques. No culture, no research!”

“I see one possible flaw,” said 2iC.

“Which is…?” asked Devil.

“When humans fall ill with this disease–lots of pain, diarrhea, blood and dehydration­- sounds as if they will be in a hospital bed. Hospitals revere cleanliness; we might be missing out on transmission by bedside care givers–potentially our most efficient disease vectors.”

“Easy,” said Devil. “At graduation we endow each health care worker, especially their physician role-models, with an adamantine sense that their own hand hygiene is always perfect, beyond improvement. And we shall have our professional transmitters of this dreadful disease.” (2)

“Brilliant,” agreed 2iC. “One last concern. Does this use of our power fall into the terms of our struggle with the Lord for the hearts and minds of humans? I mean will we be allowing for the exercise of thoughtful choice about matters in the future?”

Yes,” assured Devil. “Each human will be able to choose to wash or not to wash their

hands with soap and water for a good minute after every potential contact with the disease. Now, any idea what to call the causative agent of this new ‘pestilence that stalks in the darkness’? (3)

“Hmm,” mused 2iC. “Clostridium for the genus is a given. It will be difficult to culture and study, difficult to treat and difficult to interrupt transmission. How about ‘difficile’ for the species name- Clostridium difficile?”

“Done!” agreed Devil. “Let’s get it made as quickly as possible. I would like to have it widely disseminated in the colons of humans. Add a program to keep it more or less dormant until late in the 20th century. Our devils who monitor thought development have estimated that the human genius for finding new and ever more powerful antibiotics will have ended its ascendancy by that time.”


  1. Oughton MT, Loo V, Fenn S, Lynch A, Libman M. Alcohol rub and antiseptic wipes are inferior to soap and water for removal of Clostridium difficile by handwashing. 47’h Interscience Conference on Antimicrobial Agents and Chemotherapy. Abstract K-1376a, Chicago IL, 2007.
  1. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Pemeger TV. Hand hygiene among physicians: performance, beliefs and perceptions. Ann Intern Med 2004;141:1-8.
  1. Psalm 91, v 6.