The chart below from The New England Journal of Medicine tells us that how we die is not how we used to die: There has been a fundamental shift from deaths caused by infectious disease to deaths caused by chronic illness – heart disease and cancer.
The chart also implies something very important: If how we die can change, what is in store for us, say, 35 years down the road? Will things remain the same or are we looking at another fundamental shift?
Our leading authorities such as the World Health Organization say that infectious disease will make a comeback, so much so that a recent UK government report predicts that drug-resistant infections – a subset of all infections – will kill more people than cancer by 2050.
The reason? We’re losing our antibiotics, that wall of drugs we built beginning in the 1940s that have until recently kept most bugs at bay. But they haven’t sat idle. The bugs have spent the ensuing years figuring out how to penetrate that wall of drugs – that’s evolution for you – with the upshot that our core practices of medicine such as child birth, routine operations, and cancer treatment, will be compromised.
One more thing. Deaths by infections won’t replace deaths by chronic illness – they’ll simply add to them.
The good news is that in this case knowledge is power. We know how to slow the trend so there will be more time to develop effective drugs and other solutions. But this will involve all of us because it’s our persistent misuse of antibiotics that has accelerated the emergence of these drug-resistant bugs.
Britain’s National Health Service, who prepared the first one, tells us that poor diet, lack of exercise and smoking are the main offenders behind the high level of deaths from heart disease.
We also know that major causes of death change over time. For example, a report commissioned by British Prime Minister David Cameron found that unless antibiotic-resistant bacteria are stopped, they could kill an average of 10 million people a year by 2050, which would place it ahead of cancer.
The second chart tells us what we’re doing about these things that kill us, at least in terms of where we want the money to go.
President Obama has often said that, “My number one priority continues to be the security of the United States,” referring, in this case, to Iran.
At issue, however, is whether we should continue to define national security as simply a military matter.
The short answer is we cheat, and oh by the way, we are making ourselves sick in the process.
Let’s start with this: What weighs more – all the humans on the planet, or all the animals we raise to produce our food, i.e. cattle, pigs, and chicken? If you answered the latter you’d be right; what’s more, the balance keeps shifting in the direction of the animals.
The explanation is twofold. First, the obvious one, the Earth’s population is rapidly increasing. Right now we’re at around 7 billion and estimates are that by 2030 we’ll be at 8.5 billion: that increase is the equivalent of the current U.S. population multiplied by 5. So in order to feed all these new people we will need more food animals.
The second reason is less obvious but actually more of a factor: the rising incomes of the low and middle-income BRICS countries – Brazil, Russia, India, China, and South Africa. As people put money in their wallet their tastes quickly shift from rice to steak – and there’s the rub: the ever-increasing demand by an ever-increasing number of people for protein; i.e. beef, chicken, pork, and fish.
These are some of the points made in a study conducted by researchers at Princeton University and published last month in the Proceedings of the National Academy of Sciences of the United States of America.
Here’s the rest of what they have to say. To meet this growing demand for food we’ve drastically changed how we make it. Old McDonald had a farm. He’s been replaced by “large-scale intensive farming operations,” or CAFOs, where antibiotics are used routinely to keep confined animals healthy and to speed up their growth.
This is where the cheating comes in. Antibiotic use is this circumstance is the functional equivalent of steroid use in competitive sports. As with steroid use, growth-promoting antibiotics come with a hidden cost: antibiotic resistant disease in livestock and humans. So much so that a UK government study predicts there’ll be more deaths from resistant infections – the so-called “superbugs” — than from cancer, by the year 2050.
In other words, antibiotic use drives disease, and the more we use them the more untreatable disease we will have in society. In a very real sense, we’re actually manufacturing illness. Put another way, we’re eating disease.
Exactly how bad is the trend towards a surge in antibiotic use in our food animals? In a word – Bad. The Princeton study tells us that (1) the global consumption of antibiotics for cattle, chicken, and pigs, will increase from the 63,000 tons used in 2010 to almost 106,000 tons in 2030 – a 67% rise (2) China and the United States are and will continue to be the biggest overall offenders (3) the greatest increase in antibiotic use – a 99% rise – will be in the BRICS countries, and (3) the global increase in trade and transport make an outbreak of antibiotic resistant disease anywhere a problem for everyone everywhere (Remember the great American Ebola freakout of 2014?).
To get a better understanding of the relationship between antibiotic use in food animals and how it affects our health we recommend watching the Frontline piece The Trouble with Antibiotics, that came out last October. It’s top notch stuff. Here’s a preview:
Graham Robinson, a sales clerk at Menagerie Pet Shop in Toronto watches antibiotics fly off his shelves on a daily basis – with pet owners. “We sell out of erythromycin weekly,” he says.
Common antibiotics such as erythromycin and tetracycline are available in pet stores. And you don’t need a prescription to get them. So pet owners have figured out that you can avoid the time and cost of seeing a vet simply by going direct to the pet store.
But playing dog doctor has a huge downside for both your pet and you. The basic equation is this: Antibiotics in, superbugs out. Meaning that the more you use antibiotics the more superbugs you manufacture, thus the more likely it is that your pet will come down with an untreatable illness. And the very drug resistant bugs that made Spot sick will jump from him to you.
The way it works is nicely laid out in the graphic. Notice step 3. That’s the effect of the antibiotic – it kills off the weak bacteria leaving only the strong ones (yellow), i.e. the ones that are resistant to antibiotics. The resistant bacteria then multiply, because that’s what bugs do all day, and before you know it you have a ton of MRSA crawling around in your dog.
We reported on this last year. Researchers at Cambridge University documented the transfer of MRSA bacteria back and forth between pet owners and their “companion animals” – dogs, cats, horses, rabbits, turtles, parrots, and – would you believe – bats!
So the rule is simple. We should no more willy nilly give our pets antibiotics than we would ourselves. In both cases we risk causing serious illness.
Here’s a brief CBC report on what happens when pet owners play doctor.
Here’s an extraordinary video about a dog and his owner.
Maureen Burns had a lump in her breast and suspected cancer. However, two mammograms and a scan said she didn’t. But her dog Max, a red collie cross, was telling her something different. “He just wasn’t happy,” says Maureen. In fact, because Max was 9 ½ she thought she was losing him. Occasionally, though, Max would do something odd – he’d touch Maureen’s breast with his nose then back off “so desperately unhappy, such a sad look in his eyes.” Then one day it hit her. Staring into the mirror and looking at Max lying on her bed Maureen suddenly knew what Max was trying to tell her – she had cancer.
I’ll let her tell you the rest of the story:
As we reported last week the use of dogs for medical detective work has moved over into infectious disease as well. Notably, in the detection of the superbug C. difficile, a diarrhea-causing hospital superbug that kills 29,000 Americans every year. In principle, there’s no reason why this couldn’t be extended to other disease-causing superbugs such as MRSA.
In the latest development, scientists at the University of Arkansas, Little Rock, just reported that Frankie, a trained scent dog has successfully sniffed out thyroid cancer in people who had not yet been diagnosed with it.
Interestingly, the lab is also trying to find a new home for canine-veterans from Iraq and Afghanistan. Instead of sniffing out bombs, they will be trained to hunt for cancer.
Man’s best friend appears ready to do us another good turn.
Meet Angus, a 10 month old springer-spaniel puppy enrolled in Detective School over at Vancouver General Hospital. He’s learning how to sniff out the hospital superbug Clostridium difficile, or C difficile, before it gets hold of the patients.
The most prevalent of hospital superbugs, C difficile causes life-threatening diarrhea. It prefers the elderly, and once it gets hold of you it can return time and again, leaving you in a state of helpless anxiety between “cures.”
And there’s a lot of it. Just last week for example, a study conducted by the U.S. Centers for Disease Control and Prevention and published in the New England Journal of Medicine, concluded that C difficile causes almost 500,000 serious infections and 29,000 deaths a year.
Did you find those numbers meaningful? Because psychologists tell us that for most of us large numbers like that won’t sink in. So to get some perspective, let’s compare the harm caused by C difficile to the harm caused to U.S. troops during the Vietnam War. The total number of wounded was 153,303 and the number of deaths was 10,785 – and that was over a 20 year period that ended when the last helicopter pulled out of Saigon in 1975.
In other words, C difficile is serious business. Or as the CDC puts it, “This bacteria is an immediate public health threat that requires urgent and aggressive action.” (p.51)
The immediate threat exists mostly for hospital patients and the elderly in long term care facilities. One kind of aggressive action required is prevention – find the bug before it finds you. The trouble is, care homes and especially hospitals are large facilities. Invisible creatures can lurk anywhere, and there’s plenty of nooks and crannies to serve as hideouts. So how can we find them?
Angus! He has a nose for this kind of thing, literally. He has 125 to 300 million scent glands, while humans have a paltry 5 million or so. To appreciate the difference consider that, blindfolded, our sense of smell can detect the presence of an Olympic-size swimming pool. But a dog could find a single drop of water in 20 Olympic pools. And fortunately, diseases have specific scents associated with them too, which dogs can detect in such things as our breath, sweat, and urine.
We know that this heightened trait of smell is why we have long used our pals to detect such things as narcotics and bombs and to search for lost children. Now medical science has picked up the scent and has begun enlisting them as disease detectives. For example, about 10 years ago we saw the advent of medical assistance diabetic alert dogs to detect when a person’s blood sugar is low. Then we started programs using dogs in the early detection of various cancers, such as lung, ovarian, breast, bladder, and prostrate. And bringing us full circle, research published in the British Medical Journal 3 years ago found that dogs could sniff out C difficile with 100% accuracy. So Vancouver General Hospital is on to something here, and good for them.
Here’s a brief video where we meet Angus hard at work, as well as infectious disease specialist Elizabeth Bryce, MD, who is overseeing the program.
Just Say No … unless your doctor is sure you need them
An expansive study by the U.S. Centers for Disease Control and Prevention published in the New England Journal of Medicine on Wednesday tells us that the rate of death and infection caused by the bacterium Clostridium difficile, or C. diff, is actually about twice as much as we thought.
And what we thought was bad enough. As recent as the fall of 2013 the CDC released a report, “Antibiotic Resistant Threats in the United States,” that placed C. diff in its top category of dangerous pathogens because of its widespread harm. It killed about 14,000 Americans a year and seriously infected 250,000. Hence the CDC warning: “This bacteria is an immediate public health threat that requires urgent and aggressive action.”
We learned this week, however, that those 2013 C. diff numbers were a gross underestimate by half. The new report concludes that “C. diff was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011.” (The last year for which we have data.)
Yet even these numbers underestimate the true extent of the harm because the researchers only counted deaths within 30 days of infection, and because they only counted the initial and 1 subsequent infection – there were 83,000 of those — in the same person. This matters because C. diff can return time and again. With each subsequent infection the disease is more severe thus harder to treat, and it becomes easier to transmit to others.
The study also raised 2 other concerns.
One, people over 65 catch C. diff at a rate 8 times greater than the general population.
Two, there’s a new strain of C. diff out there that’s more severe and easier to catch. The CDC’s Michael Bell, MD, explains: “In the past, patients infected with C. diff have had diarrhea related to antibiotic use that was often perceived as a nuisance, but not a major problem. Unfortunately, the type of C. diff circulating in the US today produces such a powerful toxin that can cause a truly deadly diarrhea. Patients receiving antibiotics are now at risk for not just mild diarrhea, but intense illness that can cause damage to the bowel so painful and severe that part of the colon needs to be surgically removed.”
This brings us to the heart of the problem. “Antibiotics are clearly driving this whole epidemic,” says Dr. Bell. It works like this. Your intestines contain millions of bacteria, many of which help protect your body from infection. But when you take an antibiotic to treat an infection, it can can destroy some of the normal, helpful bacteria as well as the bacteria causing the illness. Without enough healthy bacteria, C. diff can quickly grow out of control and become the dominant bacteria in your GI tract. They would be the majority bacteria in step 3, below.
Margaret Riley, Ph.D., professor of biology at the University of Massachusetts, Amherst, offers an interesting analogy. She says taking an antibiotic is like ingesting a hydrogen bomb because it kills everything, all of your body’s bacteria, the good and the bad. In other words, antibiotics, she says, are not like a laser-guided missile that kill only the bad bacterial cells.
Sound familiar? Think cancer. Because in this sense the effect on your body of a course of antibiotics is similar to the effect of a course of radiation: in both cases you’re using a shotgun to kill a fly and so you end up with “collateral damage,” examples of which are well-known in the case of radiation therapy – hair loss, fatigue, decreased appetite, radiation sickness, and so on.
Now for the good news. You have a vital role to play in your own healthcare and you have more control than you may realize. In this context there’s a simple but important rule: Stop asking for antibiotics. That message comes direct from the Harvard School of Public Health at a public forum they held a year ago. It’s a patient-empowering discussion that we highly recommend.
You can see it in the annual polls that tell us they consistently rank at the very top of the professional heap (our friends in Congress, not so much). This reality is even reflected in our cultural narrative about them; for example, in how they’re portrayed on television. From Marcus Welby, MD, to George Clooney’s character Dr. Doug Ross on ER, to today’s Grey’s Anatomy, we are presented with a string of highly competent, caring, and properly motivated people.
But there’s a problem. The professional reputation of our best and brightest is taking a hit these days. The charge against them is that they’re over-prescribing antibiotics. This drives the emergence of resistant bacterial strains, which poses a serious threat to public health. In the words of the World Health Organization: “… the world is headed for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill …” So much so, in fact, that a recent UK government-sponsored report predicts that deaths by antibiotic-resistant infections will surpass deaths caused by cancer by the year 2050.
So the trick is to cut back on prescribing unnecessary antibiotics, especially in those cases where we know they won’t work – e.g., for most colds and the flu – or for any other illegitimate reason.
Illegitimate reasons? Take a look at this survey conducted by the online journal Medscape, that tells us why clinicians – i.e., physicians, physician assistants, and nurse practitioners – prescribe antibiotics.
That’s troubling stuff. Basing treatment decisions on patient demands or the fear of lawyers, for example, is not what we expect to see. It begs the question, where do we go from here?
And to help answer that, how wrong would it be to ask ourselves this – what would Dr. Doug Ross do?
Almost a year ago to the day, Stuart Levy, MD, a senior professor and researcher at the Tufts University School of Medicine, sat on a panel at the Harvard School of Public Health and told us what needs to be done to fight antibiotic resistance: “If I had $800,000 to spend on fighting infectious disease,” he said, “I’d spend $700,000 of it on educating the community: They need to be a partner in using antibiotics properly.”
So what’s Plan B? Take a look at this sexy ad from yesterday’s Super Bowl:
I’m sure Dr. Levy and his colleagues haven’t consider getting their message across in quite this way. But here’s the thing: it might just be working. The company that owns Carls Jr., the burger joint featured in the ad, told the Huffington Post that “sales of the burger have ‘exceeded projections’ since its debut six weeks ago.”
This matters because it’s the overuse of antibiotics that drives antibiotic resistance. And since about 80% of all antibiotic use in the US is for raising our food animals – cows, pigs, and chickens — demanding that they go antibiotic free is a big deal.
What’s more, the US Food and Drug Administration has come under heavy criticism for not policing the livestock producers for their inappropriate use of antibiotics. As the burger company puts it: “Your government is not going to protect you,” therefore, “The public is going to have to demand this for their own sake.”
Want to further increase the demand for burgers made from free-range, grass-fed cattle that are never exposed to antibiotics, steroids or added hormones? Unfortunately, repeatedly telling the public that in the US alone antibiotic resistant bacteria kill more than 23,000 people every year and seriously infect a further 2 million people seems to go only so far.
So how about this: Did you catch the acclaimed Super Bowl halftime show by pop icon Katy Perry? She happens to have more twitter followers that anyone on the planet: 64.5 million “KatyCats” follow her. She also happens to have a strong philanthropic bent that involves the health of children.
Dr. Levy said if he had $800,000 to spend on infectious disease that almost all of it – $700,000 – would go to making the public “a partner in using antibiotics properly.” And who better than Katy Perry to reach 64.5M people all at once?
So here’s the question: how many tweets would $700k buy?
If you go to the hospital and happen to catch MRSA, the assumption is you will be treated for it and that will be the end of the story. Unfortunately, we’re learning that catching MRSA in the hospital is often just the beginning of the story, and not a pretty one at that. Specifically, “successfully” treated MRSA patients are almost 50% more likely to die in the year after their release from hospital compared to similar patients who never had MRSA.
This was the conclusion of a recent US study that followed the progress of 3,592 MRSA patients after they were released from hospital. They were matched to a second group of 3,592 patients, the difference being that these patients never had MRSA. The results: Patients with MRSA hospital-acquired infections (HAIs) were 49% more likely to die within a year of their release from hospital compared to the non-MRSA patients.
The researchers offer two reasons for this: “First, the increased risk of death may be caused by recurrent infections, which are common in patients with MRSA infection. Second, recent evidence suggests that Staphylococcus aureus HAIs can lead to long-term disabilities (e.g., chronic ventilator dependence, dialysis-dependent end-stage renal disease), which may also increase the risk of death.”
Moreover, death after discharge isn’t the only consequence of a MRSA HAI. For example, other studies have found with patients surviving to discharge, 1 in 4 will require multiple re-admissions for complications due to their MRSA infection. And surgery within 30 days as well as admission to an ICU were also associated with MRSA infection.
The results of the US study alone, say researchers, “underscore the importance of [hospital] interventions designed to reduce the transmission of MRSA and the need to consider long-term outcomes when evaluating the economic impact of such interventions.”
Here’s the thing: we know how to intervene. Take the case of Canada’s Vancouver General Hospital, who were determined to cut down on the number of infections associated with major surgery. So they engaged in a year-long non-antibiotic project – thus not contributing to the rising plague of antibiotic resistance – involving more than 5,000 surgical patients. Using a combination of photodisinfection technology and chlorhexidine wipes they reduced surgical site infections by 39% and the number of readmissions due to SSIs from 4 to 1.25 cases per month. Their effort saved the hospital more than $1 million in costs.
For this work they were awarded the Innovation Award of Excellence by the International Consortium for Prevention & Infection Control which is endorsed by the World Health Organization. And from BC Minister of Health Terry Lake they earned this accolade: “Congratulations to the Vancouver General Hospital team on this significant recognition of your work as leaders in the area of infection control. This achievement is a great example of how we are turning to innovation throughout the health system as a way of enhancing patient care and safety, while reducing costs.”
So we can do it that way. Or we can continue to send the MRSA-affected patients home … and wait for them, like MRSA itself, to come back.