World Health Organization Warns of a Post-Antibiotic Era

When I was ten, my life was saved by antibiotics when I had pneumonia and pleurisy simultaneously. So this story has personal resonance for me.

It’s worth noting that 80 percent of the antibiotics used in the United States are used as a routine part of raising animals for meat, dairy, and eggs, on factory farms and other non-organic agricultural operations. That’s where the problem most urgently needs to be addressed. The private sector isn’t doing anything about it, which means it will require regulatory action at the federal level. The sooner the better.

The ‘post-antibiotic’ era is near, according to a report released today by the World Health Organization (WHO). The decreasing effectiveness of antibiotics and other antimicrobial agents is a global problem, and a surveillance system should be established to monitor it, the group says.

There is nothing hopeful in the WHO’s report, which pulls together data from 129 member states to show extensive resistance to antimicrobial agents in every region of the world. Overuse of antibiotics in agriculture — to promote livestock growth — and in hospitals quickly leads to proliferation of drug-resistant bacteria, which then spread via human travel and poor sanitation practices.

“A post-antibiotic era — in which common infections and minor injuries can kill — far from being an apocalyptic fantasy, is instead a very real possibility for the twenty-first century,” writes Keiji Fukuda, WHO assistant director-general for health security, in a foreword to the report.

Perhaps the most worrying trend is the spread of resistance to carbapenems, the ‘antibiotics of last resort’, says Timothy Walsh, a medical microbiologist at Cardiff University, UK, who was an adviser for the report. “That’s taken us by surprise,” he says. “All of us are rather like rabbits in front of the headlights in how quickly this has taken off.”

 

Pesticides and the Collapse of Bee Colonies

The alarming collapse of the bee population in many areas appears to be due to a widely used class of pesticides called neonicotinoids. Should this be allowed to continue, it has the potential to wreak havoc on the world’s food supply, much of which is dependent on bees for pollination. No small thing.

At first, there had been concern that electromagnetic waves from increasingly ubiquitous cell phones might be the cause, or reduced resistance to mites or parasites, research failed to document a strong link. But with neonicotinoids, the evidence is now strong to the point of damning.

From the Harvard School of Public Health:

Two widely used neonicotinoids—a class of insecticide—appear to significantly harm honey bee colonies over the winter, particularly during colder winters, according to a new study from Harvard School of Public Health (HSPH). The study replicated a 2012 finding from the same research group that found a link between low doses of imidacloprid and Colony Collapse Disorder (CCD), in which bees abandon their hives over the winter and eventually die. The new study also found that low doses of a second neonicotinoid, clothianidin, had the same negative effect.

Further, although other studies have suggested that CCD-related mortality in honey bee colonies may come from bees’ reduced resistance to mites or parasites as a result of exposure to pesticides, the new study found that bees in the hives exhibiting CCD had almost identical levels of pathogen infestation as a group of control hives, most of which survived the winter. This finding suggests that the neonicotinoids are causing some other kind of biological mechanism in bees that in turn leads to CCD.

Prescribing Antipsychotic Drugs to Kids

Consumer Reports looks at current practices and finds them alarming:

The number of children taking powerful antipsychotic drugs has nearly tripled over the last 10 to 15 years, according to recent research. The increase comes not because of an epidemic of schizophrenia or other forms of serious mental illness in children, but because doctors are increasingly prescribing the drugs to treat behavior problems, a use not approved by the Food and Drug Administration (FDA). And a disproportionate number of those prescriptions are written for poor and minority children, some as young as age 2.

Doctors are prescribing antipsychotics even though there’s minimal evidence that the drugs help kids for approved uses, much less the unapproved ones, such as behavioral problems. And to make matters worse, the little research there is suggests the drugs can cause troubling side effects, including weight gain, high cholesterol, and an increased risk of type-2 diabetes.

This pattern repeats itself throughout the medical system. A drug that may be helpful for certain severe cases is prescribed for vastly greater numbers of people. As we move down the severity scale, the risk-benefit ratio gets worse and worse. Milder cases (even assuming the diagnosis is correct) are those least likely to benefit from drug treatment and most likely to have a cost-benefit ratio that’s underwater.

Defending the Patient Protection and Affordable Care Act

In response to my op-ed in the Kansas City Star this week, I received a wide range of comments. Most were quite supportive. Others were, shall we say, less than enthusiastic about various aspects of the health reform law.

My reply to those commenters:

Regarding the questions you shared with me about the Patient Protection and Affordable Care Act …

The United States is the one nation in the developed world that has not made a decision as a nation to consider health care a fundamental right. The health reform law (Patient Protection and Affordable Care Act of 2010) is the first major step in that direction since the passage of Medicare and Medicaid in the 1960s. It has many moving parts because it builds on the existing flawed system rather than switching to a single payer system, as was done in varying ways in other nations. Some of those other countries maintained private insurance companies but only as nonprofit entities; others went all in with government as the sole payer and/or administrator. The United States is the only developed nation that has private insurers that have to answer to shareholders. I would argue that this is a bug, not a feature.

In my view, all systems have their own unique strengths and weaknesses. The pre-PPACA U.S. system has the unique track record of having the highest (by far) overall per capita health care expenses in the world at the same time that it has many of the worst health outcomes in the developed world. So we begin with a system that is highly problematic, and to cap it off also leaves tens of millions (50M?) uninsured, something does not exist in any of these other nations. Before diving into any particular strengths and weaknesses of PPACA, I think it’s critical to acknowledge that the system on which it seeks to improve is drastically flawed. On at least that one point, I would imagine that both proponents and opponents may agree.

Continued after the jump …

My Op-Ed on Medicaid in Kansas City Star

The Kansas City Star has just published my op-ed based on my experiences this year on the Missouri Citizens and Legislators Working Group on Medicaid.

At least a dozen physicians from safety net clinics shared stories of their uninsured, “working poor” patients (most of whom would be covered if Missouri accepts Medicaid expansion) who can’t afford the medicines or other treatments prescribed for their diabetes, heart disease, hypertension or chronic pain. As a result, they spiral downward, suffering greatly as their previously manageable ailments become unmanageable (such as treatable diabetes descending into kidney failure) , at which point their now-severe disabilities allow them to finally qualify for Medicaid, but too late to regain their health.

Read more here: http://www.kansascity.com/2013/11/12/4616981/tough-choices-on-medicaid-ahead.html#storylink=cpy

 

FDA Moves Against Trans Fats

This move should complete the elimination of artificial trans fats from the American diet. Previous advice from the government had already lowered the amount of trans fats in packaged foods substantially.

On the basis of a review of scientific evidence and findings from expert panels, the agency made a preliminary determination that the oils “are not generally recognized as safe for use in food” and should be eliminated, FDA Commissioner Margaret Hamburg, MD, said on a conference call with reporters.

The decision “is very welcome and strongly supported by massive scientific evidence that trans fat has many adverse effects on health,” Walter Willett, MD, DrPH, of the Harvard School of Public Health, said in an email to MedPage Today. “Trans fat has no place on the table, and this step will help make the diets of Americans safer.”

Harvard School of Public Health’s Walter Willett, PhD, puts the change into context:

Willett added, “Further removal of trans fats will also likely nudge down rates of diabetes, obesity, and other conditions as well.”

“Importantly, by getting trans fat off the table entirely, we will be able to focus attention on other aspects of diet that also need to be improved,” he said. “This will likely have a ripple effect worldwide because other countries are considering similar actions.”

Despite Practice Guidelines for Back Pain, Prescriptions for Narcotics Rise While Those for NSAIDs Fall

Medical practice guidelines are voluntary. Sometimes, this leads to clearly dysfunctional outcomes.

This interview with the author of a new article in JAMA Internal Medicine underscores the conclusions reached in the 2010 study by Bishop and colleagues at the National Spine Center in Canada, published in Spine Journal, which found management of low by pain by primary care medical physicians (PCPs) to be highly “guideline-discordant” with regard to medications. (Bishop’s article also found that for low back pain, guideline-based care that includes spinal manipulation by chiropractors is significantly more effective than usual care by PCPs).

The new JAMA Internal Medicine article’s lead author is John N. Mafi, MD, chief medical resident and fellow in general medicine at Beth Israel Deaconess Medical Center in Boston:

We saw a decline in use of NSAIDs that was discordant with the guidelines. The guidelines recommend it as a first-line treatment. What we are seeing instead is a rise in narcotic prescriptions. The guidelines are cautious about narcotics and say to be cautious and recommend them only as second- or third-line therapies.

There is also discordance between the guidelines and physician use of imaging. In patients with new-onset back pain, ordering an MRI or CT scan is not indicated in most cases. Finally, we saw a rise in referrals to specialists, though primary care clinicians are usually able to manage patients with routine cases of back pain themselves with minimal treatment.

news@JAMA: What do you think is driving physicians to pursue these more aggressive treatment approaches?

Dr Mafi: We are a society that demands instant solutions, but back pain doesn’t play by these rules. It takes time, and unfortunately, the fancier treatments haven’t been shown to decrease patient’s pain or increase their quality of life. That’s why we have to rely on the less-is-more approach.

news@JAMA: What do you think is driving the shift from NSAIDs to narcotics?

Dr Mafi: It is in part patient expectations and a sentiment that emerged in the 1990s physicians weren’t paying enough attention to patient pain. The Joint Commission made pain the fifth vital sign. In response, there has been an overcorrection and now narcotics are reached for first. Since that time, there has been a 300% increase in narcotic prescriptions and rise in narcotic overdoses and deaths. In 2008 almost 15000 people died—more than for cocaine and heroin overdoses combined. There are huge public health implications.

References:

1. Mafi JN, McCarthy EP, Davis RB, Landon BE. WOrsening trends in the management and treatment of back pain. JAMA Internal Medicine. 2013 (epub before print).

2. Bishop PB, Quon JA, Fisher CG, Dvorak MFS. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal. 2010;10(12):1055-1064.

Southern (and Some Northern) States Choose to Leave Millions of Their Citizens Uninsured

This intransigence will bring with it a great deal of unnecessary suffering, death and, not so incidentally, economic hardship in its wake. Will they change their minds eventually? Only if their own citizens force them to.

From the Institute of Southern Studies:

But in Rome, 27 percent of adults under 65 are uninsured, a rate that holds true across the state. Last year, the city’s two hospitals report spending more than $80 million delivering uncompensated care, often in the emergency room, where costs run high. Taxpayers and those with health insurance will end up paying for that care through government subsidies and higher premiums, industry experts say.

Rome’s dilemma is exactly the situation that the Patient Protection and Affordable Care Act, also known as “Obamacare,” was designed to fix — but that fix isn’t coming to Georgia.

The Patient Protection and Affordable Care Act provides for expansion of insurance coverage for low-income and middle-class adults, with the goal of reducing the $41 billion spent covering uninsured care each year.

A key provision, set to kick in on Jan. 1, 2014, offers states federal funding to expand Medicaid coverage to all adults making up to 133 percent of the poverty line, or $25,975 for a family of three. In Georgia, over half of that group is uninsured.

But in the Deep South and Florida, Republican governors and state legislatures have turned down the funding, citing cost concerns and philosophical opposition to the safety net insurance program, which was signed into law on July 30, 1965. In Louisiana, Mississippi, Alabama, Georgia, South Carolina and Florida, the move will exclude 2.7 million low-income residents from Medicaid eligibility, according to the Urban Institute.

“In Georgia, these people are the working poor,” said Dr. Leonard Reeves, a family physician in Rome who volunteers at the city’s privately-funded free clinic. “I had an uninsured patient in his late 30s who worked every day of his life, and one day he finally came in when he felt he couldn’t go on any more.”

Dr. Reeves diagnosed the man, who was married and worked part-time as a forklift operator, with diabetes, but it was too late for insulin. After years without basic treatment, his kidneys had failed, and he needed weekly dialysis treatments to stay alive.

“He’s now on disability,” said Dr. Reeves. “If he’d had that insurance, he’d still be paying into the tax rolls instead of taking from them. There’s an old saying — ‘An ounce of prevention is worth a pound of cure.’ And that’s exactly what we’re talking about here.”

 

EPA Backs Off Factory Farm Regulation

Whether it’s a Democratic or a Republican administration, favoring corporate power over the well-being of the public seems to carry the day more often than not. What a disappointment this administration has been on these types of issues.

The Environmental Protection Agency is obliged under the Clean Water Act to monitor America’s waterways and shield them from the toxic runoff from factory farms. But the growth of that industry, and its courtroom tenacity, has far outstripped the E.P.A.’s efforts to restrict runoff from manure lagoons and feedlots.

Last year, the agency meekly withdrew two proposed rules. One would have gathered basic information from all factory farms. The other proposed rule would have expanded the number of such farms required to have a national pollution discharge permit. Fewer than 60 percent do now.

Then, last week, in yet another retreat, the agency announced that promised new regulations governing feedlot discharges nationally would not be forthcoming.

According to the E.P.A.’s own studies, agricultural runoff is the leading cause of impaired water quality. The amount of manure produced by factory farms is staggering. The agency estimates that those operations create between 500 million and 1 billion tons of manure, three times as much waste as humans produce in the United States. The task of keeping those hundreds of millions of tons of animal waste out of rivers, lakes and estuaries is enormous, clearly requiring a strong set of revised regulations for the handling of factory-farm waste, including provisions for tracking waste when it’s been moved offsite.

Right now, the patchwork of regulations — which assume a great deal of self-policing — suits the factory-farm industry all too well. So does the E.P.A.’s inability to gather even the most basic information about those farms.

 

Supreme Court Rules That Human Genes Cannot Be Patented

This may be best Supreme Court decision in recent years. Human genes may not be patented. Those that have patents on genes no longer have them.

I confess to some surprise at this decision. But my main emotion is elation.

The decision was unanimous.

“A naturally occurring DNA segment is a product of nature and not patent eligible merely because it has been isolated,” Justice Clarence Thomas wrote for a unanimous court. But manipulating a gene to create something not found in nature is an invention eligible for patent protection.

The case concerned patents held by Myriad Genetics, a Utah company, on genes that correlate with increased risk of hereditary breast and ovarian cancer.

The central question for the justices in the case, Association for Molecular Pathology v. Myriad Genetics, No. 12-398, was whether isolated genes are “products of nature” that may not be patented or “human-made inventions” eligible for patent protection.

The patents were challenged by scientists and doctors who said their research and ability to help patients had been frustrated.

The court’s ruling will shape the course of scientific research and medical testing, and it may alter the willingness of businesses to invest in the expensive work of isolating and understanding genetic material.