Stories of Ordinary Medicine: Between Parasites and Simulants
Although from Brno, when Jiří Kubek graduated in 1973, he headed to Dačice for experience. In the town of sugar cubes he sharpened his medical spurs, met the love of his life and, despite the discouragement of his colleagues, became passionate about infectious medicine. He returned to his hometown and went straight to the Infectious Diseases Clinic of the Brno University Hospital and added a certificate in communicable diseases to his certification in internal medicine in 1980. During his professional career he experienced the eradication of smallpox, the first patients with HIV, but also the memorable hepatitis epidemic, during which in 1979 over forty thousand people across the country were infected with the disease transmitted from frozen Polish strawberries. Dr. Kubek spent the last eleven years before his retirement at the Infectious Diseases Department of the Brno Prison Hospital. He is said to have retired among the inmates. We met at his house in Bohunik, within sight of where he had been commuting for thirty-six years. The experienced infectologist poured me mineral water from a bottle to tell me what those years were like. Although tap water is always enough for me, at the end I understood why...
I know your son is a doctor, too. Were your parents doctors, too?
No, they were teachers. My dad was born in 1898 and fought in World War I. He had a more troubled life. During the First Republic, in 1921, he joined the Communist Party and stayed there until 1968, when he finally sobered up. Fortunately, I never joined the party. Common sense told me not to.
You weren't even pressured to do so?
My boss, Professor (Pavel) Ježek, persuaded me a couple of times, and it's true that if I wanted to have a career, I would have had to be in the party. At that time they appealed to us to write some revolutionary socialist texts for the ROH. After a while I perceived more that this was not in line with my Christian convictions and I asked the directorate not to do it. I was called to the directorate for an explanation. In the end, surprisingly, I was not sanctioned for it.
So you're a religious person?
Yes, I'm a believer. I am baptized, but I was brought to faith by my wife, whom I met while working in Dačice.
Was Masaryk University Medical School the obvious choice for you after high school?
I went to high school in Brno at Lerchova and I was always drawn to nature. During the holidays we used to go to Hodice, in the Highlands, where I used to hunt crayfish and fish as a boy, and originally I wanted to be a forester, later a vet or agronomist. But I was discouraged when I was on a trip with a vet and saw him kicking a cow. I didn't like that. I applied for medical school at the very last minute and luckily it worked out.
How do you remember the events of August 1968, when you entered your second year in a completely different political climate?
I was made ring leader because of my good results in the entrance exams, but I was replaced after '68... Although, I was actually glad, because I never felt I was in a leadership position.
“Associate Professor Korbicka used to say: "A peasant must eat a pile of dung in his lifetime. And a pathologist...'”
Jiří Kubek
Do you recall any particular teachers from your student days?
Professor (Lubomir) Malinovsky in anatomy, for example. And Professor (Karel) Žlábek used to come to us for dissections. A lot of people were burnt out on anatomy, although it was important to overcome it, of course. I remember when at the first autopsy Professor Žlábek said "Hic mortui docent vivos", there was a terrible bang and one of my classmates fainted. (smiles) Then there was pathological anatomy, which was lectured by Professor (Josef) Švejda, and he was excellent. I remember him fondly...
You've mastered anatomy and body work?
I only got sick once during a bloody operation, but then you get used to it. Although at first we were worried about catching an infection from the bodies. Docent (Josef) Korbička used to say: "A peasant must eat a pile of dung in his lifetime. And a pathologist..." (laughs)
Who else can you think of?
Professor of biology (Oldřich) Nečas influenced us a lot. He was such a charming elegant man with black hair and bright blue eyes. Or professor (Vladislav) Kruta, an excellent physiologist, well-known even abroad, even though only a few people attended his lectures... Another great personality I remember was Jan Černý, who was still an assistant at the Second Surgical Clinic at St. Anne's and later became the head of cardiac surgery. He was incredibly clever, everyone admired him.
destiny in highlands
After your studies you went to work in Dačice. Why there?
At that time a lot of people were running abroad, so I would have had no problem getting a job in Brno at the internal medicine department, but I thought it would be good for me to be a bit more independent. So I headed for the Highlands, which I always liked. And then I met my wife there. In Dačice there were only three departments besides the internal medicine - surgery, gynaecology-obstetrics and paediatrics - so when patients with other problems came to us, you had to be able to cope, which was a big plus. But then, when I talked to other colleagues, I felt the need to specialize in something. I became interested in infectious diseases, so after I graduated in internal medicine in České Budějovice I headed to the Infectious Diseases Clinic in Brno Bohunice (IDC).
Did you have the mandatory surgical round after you came in?
Sure, I did. Although the director needed a substitute in gynaecology at that time, so he sent me there with the understanding that he would give me credit for the rest. I ended up having sixty-nine deliveries! But then I had to go to surgery anyway...
What got you excited about infectious medicine in particular?
I've had a relationship with animals since I was a boy, catching frogs, tadpoles, fish, divers and so on. Parasitology, which I later took up, is also close to that. So I guess it was due to my positive relationship with nature. But I remember Mr. Verner, the chief physician, who said to me back in Dačice: "Colleague, infections, in the age of antibiotics? It has no future!" (smiles)
The construction of the University Hospital in Brno Bohunice began in 1969 and lasted until the end of the 1980s. What was it like when you came to Brno to work at the Infectious Diseases Clinic?
At that time, besides infectious diseases, there was tuberculosis - pulmonary, then a separate building for psychiatry and orthopaedics. The problem of the hospital was that there was no surgical department, but a consultant surgeon from St. Anne's Hospital or the Trauma Hospital came to us. At the Department of Infectious Diseases we had a small operating theatre within the ICU, which was used for patients who could not be admitted to the surgical wards in Brno or other hospitals in the South Moravian Region. Necessary acute surgical interventions were performed there. I recall a case from the service of a patient with foot-sickness - Clostridium perfringens. The consultant, an experienced surgeon, assessed that the leg was suitable for amputation. However, there was no amputation saw in our instrumentation at the time. Rather than go to St. Anne's to get all the instruments, he got a hacksaw out of the car, we sterilized it, the amputation took place, and the patient was saved.
But otherwise, the options for an infectologist back then must have been very limited compared to today, right?
We didn't have antiviral drugs for hepatitis B then, so sometimes people died of that too. Yet today it's "plain B" for which there are antivirals that reliably stop it. Infectious disease clinics were, of course, used to isolate and treat communicable diseases - airborne, waterborne, foodborne, contact. But sometimes it served as isolation for certain kinds of chronic infections, where patients contracted diseases that would normally be treated in surgery, neurology, and other specialized departments. For example, at the time I joined KICH there were several carriers of bacterial typhus in the South Moravian region. We knew them, we knew where they lived, and if they had a problem, they had to come to our infectious diseases department.
Do you recall any specific patient case from these times?
We had a patient who had osteomyelitis, an inflammation of the bone in which salmonella had grown in the skull bone. The consultant neurosurgeon came in and I assisted him in the operation, where we cut out the bone, sterilized it, and after some time, when it had healed, we put it back into the patient's head. Well, it was very colourful here... We also had a case of an elderly lady, a typhoid bacillus carrier, who was taken to the hospital in Vyškov, but they didn't know about her. It wasn't until they brought her there that they found out and brought her to us. But even during that short stay it happened that a lady who was helping with the laundry in Vyškov got infected because she was smoking...
So from the infected to the laundry, from the laundry to the hand, from the hand to the cigarette, and from the cigarette to the organism...
Oh, yeah. Some infections are still underestimated when they could easily be prevented.
“The consultant assessed the leg for amputation. There was no amputation saw in our instrumentation at the time. Rather than go to St. Anne's to get all the instruments, he got the hacksaw out of the car, we sterilized it, the amputation was performed, and the patient was saved.”
Jiří Kubek
At the time of your arrival at the Brno University Hospital in 1977, the head of the Infectious Diseases Clinic was Associate Professor, later Professor Pavel Ježek, who took over from Professor Václav Houbal, right?
Yes, but I remember Professor Houbal too, he tested me in the infectious diseases department in my fifth year. Professor Ježek was a capacity for hepatitis. He was a good diagnostician, scientist, but also a boss. He was also non-partisan, which was rather exceptional for his position.
In the 1980s, Professor Jezek was focusing on new treatments for hepatitis, so you must have been there quite immediately too. How do you remember those times?
It depended on the type of hepatitis. If it was B, it could get to a severe stage and sometimes someone died. In order to overcome the period when the brain is clouded by toxic substances that the liver processes, they did so-called hemoperfusion, in which the blood was purified through activated charcoal. I remember one time I was called right at Christmas when a hemoperfusion had to be done on a pregnant patient... Those were the early days, although in differential diagnosis we dealt with a lot of other diseases and even genetic disorders where the liver was failing...
In 1979, the country was rocked by an epidemic of hepatitis A, when over forty thousand people were infected by frozen strawberries from Poland. How did you feel in your department?
I was the youngest man then and the third in line after Professor Ježek and Assistant Professor (Zdeněk) Černý, and I was assigned to take an ambulance to the field. Brno was not so affected, so we went to the risk areas, where hop brigades were taking place and where there was a risk of someone getting infected, and looked for people who had symptoms. I used to go around Podbořany, around the hop brigades where there were a lot of combers - students, and after all, jaundice is a disease of dirty hands. If we found someone with suspicious symptoms, such as dark urine, we would take them to the hospital in Podbořany for diagnosis.
to the pharmacy all the way to Vienna
Do you remember any other, similarly massive, spread of a disease?
I recall a case of a chalet in the Sumava region where they drank unboiled water from a well. But there was another hut above them where a person infected with hepatitis A was staying, and several dozen people gradually became infected through the water. The only one who got infected with the least liver damage was a guy who claimed he had only been drinking beer the whole time. (laughs)
I remember a holiday in Croatia when the whole trip was plagued by indigestion, except for one couple who drank only wine spritzers and Bavarians for the whole stay...
And do you know why? Alcohol doesn't disinfect, as it is sometimes said, but it does increase the acidity of the stomach, which destroys the bacteria that get into the body. Well, I remember two epidemics in the school cafeteria. One was what's called staphylococcal enterotoxicosis, the causative agent of which is golden staphylococcus, which is commonly found on the skin. The infection can then spread when a cook has, for example, a cut finger, which festers and the bacteria get into the food. And I remember from when I was a student that scarlet fever also spread from the canteen.
Did you catch it, too?
Fortunately, I didn't. I used to like to go to the university library to study because I found the silence soothing, and then my friend and I used to go to Sputnik in the Czech Republic to eat. We used to like to have fish salad there, but I wouldn't have fish salad today! (laughs) I'm always amazed at all the things I used to do. Catching mice in my hands, which can lead to serious leptospirosis...
Later you specialized in parasitology and tropical diseases. How big a topic was it in the 1980s? Nowadays it is not difficult to bring back a parasite from a holiday in an exotic destination, but during socialism the possibilities to travel were quite limited...
When I became interested in parasitology, the most common ones were roupi, here and there a roundworm or here and there someone brought in a bag of tapeworm cells, cases of toxoplasmosis. But all that was minor. Even under socialism, however, students from Africa came here, and sub-Saharan Africa is the most risky destination from the point of view of parasitology. We're talking about hundreds of thousands, maybe a million, of children dying within a year of life, although today the numbers may be lower thanks to vaccination... But we also had travellers. Ruda Švaříček, for example, and others, used to come here repeatedly with malaria. If he arrived with fever and chills in the forties, we suspected malaria, of course, but we still had to determine what type, because then the treatment depended on it. Some are severe, others less so, but they require what is called a 'reassurance treatment' so that they don't reappear later. Our first clue was the haematologists, who were able to detect the parasite in the blood cells from the blood count, but could no longer tell which type of Plasmodium it was. Therefore, on my own initiative, I arranged an internship with Dr. (Oleg) Ditrich from the Academy of Sciences in České Budějovice to learn how to distinguish the different types of malaria.
So foreigners and travellers were actually valuable study material for you, weren't they?
The Africans were a beautiful confirmation of the importance of immunity. The children who survived the malaria developed immunity and then as adults they were actually just getting booster doses of plasmodia from the mosquitoes to help maintain it. We had a case of a student, I think from Burkina Faso or Benin, who studied with us for a few years, then returned home, and as his immunity developed during his stay in the Czech Republic, when he came back, he immediately fell ill with malaria.
How were medicines for these exotic diseases found then?
It's true that there weren't that many cases, and there was austerity, so even if there was a bank of drugs like intravenous quinine, it wasn't easy to get them. I remember a patient for whom I wrote a prescription for mefloquine, but he had to go all the way to Vienna to pick it up...
“When the first case of AIDS appeared in our hospital, we had to take the patient to the Yellow Hill for a CT scan. They barricaded themselves in there for fear of infection.”
Jiří Kubek
Parasitologists Jaroslav Flégr and Julius Lukeš voluntarily introduced toxoplasmosis and tapeworms into their organism. Have you ever tried a similar experiment?
No, I haven't. I'm rather timid. (smiles) But it is a fact that stimulation of the immune system by parasites is confirmed.
In 1995, the biggest flu epidemic in the Czech Republic to date, allegedly spread from South Moravia? How do you remember it?
Actually, I don't remember it particularly. When epidemics like this break out, lots of people get sick, but the ones who end up in hospital are usually those who are available, for example the elderly or those with compromised immunity. And I don't recall that year being anything special... The bigger fuss was when the first case of AIDS appeared in our country in the late 1980s. We were all scared before we got a feel for it... I remember going with a patient to the oncology clinic on Yellow Hill, which we didn't have in our hospital at the time, and they barricaded themselves in there for fear of infection... Today we have drugs that can prolong patients' lives, but there wasn't much we could do about it then. The advances in medicine are enormous!
in jail
In 2002, you joined the infectious disease ward of the Brno Prison Hospital. What brought you there?
At that time, a colleague from the pulmonary department, Dr. Šarmanová, who worked in the tuberculosis department, came to me. Besides that, the prison hospital also had an internal medicine, psychiatry and rehabilitation, but there was no one to do infections there. They came to me with the director of the hospital and tempted me - I must say - for money, but also for a smaller volume of work. Because when you have a wedding coming in with salmonella from the wreaths, you have twenty or more people you have to deal with acutely...You only get that many patients at one time in civilian life.
So there was a lower volume of work in the prison hospital?
The infections in prison were most often viral hepatitis in drug addicts who had tattoos or were taking drugs even in prison. Then diarrhoea or respiratory infections. But there weren't that many. So yes, less work and better financial conditions. After all, we were already thinking of getting a house at that time... I just thought I'd give it a try and ended up staying there until 2013 when I retired.
I was surprised that you went to work in the prison so late in your career, in a position that I guess your colleagues are not very keen on...
Well, it's not exactly a popular position. Not that we're directly threatened by the prisoners, but it's not pleasant. Psychopaths, they're everywhere, but we had a lot of drug addicts, or simulacra... It was difficult to decide in the service, for example, that someone was suspected of having a heart attack, and to enforce it in the operating department, which has the decision-making power. Because once that patient is transferred to a bed in a civilian hospital, he or she has to be guarded there around the clock, which is a burden for the prison service. So sometimes one was between Skylla and Charybdis, as they say.
Did you experience any adrenaline situations in prison?
I've had inmates set fire to a mattress while on duty and managed to escape out of the building in the smoke. The inmates were led out into the yard in confusion, and everyone, including the guards, inhaled carbon monoxide, and one of the inmates started climbing up one of the guard towers. The police had already surrounded the whole place, and the firemen were there, so he had no chance to get out, but one of the guards was so stressed that he fired two warning shots, and if he were to fire a third time, he would have to aim at the prisoner. And that's not easy, he was very agitated and his blood pressure was very high. I've been in a few risky situations like that.
What other ones?
For example, a patient who had what is called hereditary angiopathy, a very rare disorder that causes a person to swell when injured. And this inmate here was at the dental clinic for a tooth extraction. When a person starts to swell after a procedure like that, or maybe after another injury, it's commonly managed with corticosteroids or adrenaline, but in the case of angiopathy, none of that works. There's a special antidote that patients are supposed to carry, but the person in question didn't. He started swelling, threatened to choke, and now what to do. Fortunately, I remembered a colleague from immunology who was just shopping in the Kaufland next door, and when I called him, he looked up the person in question in the immunology department - because only a few individuals in the Czech Republic really have that diagnosis - and found the antibody and managed to get it into the prison and give it to him. Because otherwise I don't know...
“I once happened to be doing a medical check-up on a prisoner who was clearly a psychopath and he suddenly picked up a table and threw it at me.”
Jiří Kubek
Do I understand correctly that prisoners from all over the country came to Brno for infectious diseases?
Yes. In Prague, they have an internal medicine and surgery department, so when we needed to transfer someone with an appendix, for example, we went to Prague, of course with security guards and sirens, because there was a threat of an ambush. This has happened in the past, too, when a prisoner was being transferred and his accomplices were waiting for him on the way...
Suicides happen in prison too, don't they?
Yeah. We had a high-risk drug patient transferred in from psychiatry for hepatitis. Psych wards are in cells that are empty, so they have no way to hurt themselves. In ours he was in a normal cell and the guard kept an eye on him, but somehow he still managed to hang himself behind the toilet. The guard cut him off and we managed to resuscitate him, he recovered.
A young person cannot be a prison doctor, he says, because an older person is more likely to win the respect of the prisoner-patients. Is that true?
It should be a man with experience. I mean general. It's one of those jobs that young people are not suited for, just like a politician. I think you should only enter politics with some personal experience. It happened to me once that I was investigating a prisoner who was clearly a psychopath, and he suddenly picked up a table and threw it at me. Luckily I was unharmed, the guards jumped on him right away. That was more of a funny story, but my point was that when a patient starts to convince you of something, you have to have experience to know that he's lying...
You mean the simulacra now?
Of course, and there were. One patient came to me almost every shift. (smiles) If I hadn't already had that experience of internal medicine and infection, I probably wouldn't have made it, but it was fine like that before I retired. Although, in retrospect, I'm amazed that I made it through the years, because I'm quite an anxious character otherwise.
Can a prison doctor disregard the fact that he is treating a person who has committed a crime?
You have to look at the prisoner as you would any patient and do your job. The fact that someone is a simulacrum or a serious criminal, that's extra.
Did you know what this patient was convicted of?
The guards knew, and they usually told us what to watch out for. If there was a mobster...
So you treated some prominent figures in prison?
I'd rather not name anyone in particular, but I did. We were warned that someone might try to bribe us...
Did being a person of faith help you in your work in the prison service?
Yes. One patient came to me saying he was a believer and wanted to get something out of it. I told him I was a believer too and that I was trying to do my job. Seriously, my faith - and my wife - helped me a lot mentally.
(Wife interjects.)
Wife: I was working as a nurse and you can't look at the patient to see who they are. That shouldn't matter in the case of medical care. What bothered me was not that it was a prisoner, but that one could not go to the patient alone when needed, but always had to go with a guard, who perhaps did not always have time. I couldn't do it that way.
Have you ever brought work home from the infectious disease clinic or contracted a disease at work?
No, never. I used to get sick most often when the children brought a cold from kindergarten or school, and then I caught sinusitis from it. But it's a fact that when we worked with hepatitis A, it used to be risky. I guess we didn't always wear gloves and we weren't vaccinated against VHA at the time. I remember one suspected case of smallpox that we were scared of on the ward... But otherwise I was used to wearing a drape all the time, we had lavatories with disinfectant in the corridors, so when I took those precautions I was calm. Although also once, when we were not vaccinated against VHB, I resuscitated a patient with hepatitis B, he was vomiting blood, I had it everywhere. I was a little worried about that too, but I didn't get sick...
How did you feel about the onset of the covid-19 pandemic?
I was a little worried at first, but I did everything I could to avoid getting infected. (smiles) The whole situation was unexpected and unusual, because often healthy people with very good immunity got sick, but as it turned out, it was the very good immunity that was doing the mischief, because the cytotoxic lymphocytes that bite into the virus were also biting into the tissues. That's why the severe pneumonia occurred, and that's why people died of severe respiratory failure. In this way, covid-19 had a different course than the diseases that we have known, whether we are talking about avian flu, other types of influenza and other respiratory viruses, or dengue fever, for example.
“I know I'm annoying my wife with my professional deformity, but I won't have spread with niva anymore and she has to make me sandwiches with pork ham instead of chicken.”
Jiří Kubek
When you mention here, there has been talk recently about how, as the climate changes and the range of some species shifts, so does the range of diseases that some animals can carry. So your successors are probably going to be dealing with different types of disease in a few years than you have been dealing with, aren't they?
It is a fact that anopheles mosquitoes, theoretically carriers, are already common in South Moravia. But they have been before. There was also the so-called airport malaria, when a mosquito got on a plane from a malarial location... I also remember that there was already a case of leishmaniasis in our clinic, which is a very severe parasitic disease, and the gentleman was already on a respirator... This is a liver-eating protozoan that is transmitted by mosquitoes, which are already found in the Mediterranean... It is therefore important to protect yourself with repellents and mosquito nets.
Did you develop any professional deformation during your career as an infectologist and parasitologist?
(both he and his wife burst out laughing)
JK: A very big one. For example, when my wife makes spreads, I don't mess with niva...
Wife: I had to adapt my cooking and get used to the fact that when we have a visitor and I prepare the snacks, my husband comes and sniffs to see if anything is smelled and if everything is cooked sufficiently.
JK: You know, over the years! People would come in with problems and when I asked them what they ate, they would say the grilled chicken at the fairgrounds... It was always like that! Because they, when they grill it, so that it doesn't lose weight, they don't finish it... When I saw all the things it can do, I'm more worried about those alimentary diseases than I am about some respiratory or tropical diseases.
So you've gradually adjusted your diet over the years?
JK: I know I annoy my wife when she has to make me sandwiches separately... With pork ham instead of chicken. (laughs)
Wife: My husband doesn't drink unboiled water in the summer.
JK: For example, once in Prague there was a water main accident, which was unfortunately placed under the sewer. In Milwaukee, America, the cryptosporidium got into the water system and four hundred thousand people got sick...
Wife: My husband is a great preventativeist, but nothing should be overdone. If you boil the water, all the calcium stays in the pot, and because he missed it, he broke several vertebrae while working in the garden.
So now I'm taking calcium tablets!
