Monday, May 30, 2016

Super Bug?

The “mutant super bug” has been in the limelight during the past week.  The background of this story is well known. Along years, natural selection has equipped many of the human and animal pathogens with resistance genes to major antibiotics. This phenomenon is particularly worrying in case of multidrug-resistant strains of Gram-negative bacteria, including Pseudomonas aeruginosa, Salmonella, Escherichia coli, Yersinia pestis, Klebsiella and Shigella.  Colistin was one of the last antibiotics effective against these multidrug-resistant bacteria.

In 2015, an Escherichia coli strain provided with a  resistance gene to Colistin was identified in China and then in Europe and Canada. In early May 2016,  the Multidrug Resistant Organism Repository and Surveillance Network (MRSN) at the Walter Reed Army Institute of Research (WRAIR) in Pennsylvania identified the Colistin-resistance gene in a clinical sample from a urinary tract infection collected from a patient hospitalized  in a military treatment facility. Epidemiologists – and subsequently the media – have interpreted this event as the herald of a dreadful wave of pan-drug resistant bacteria. “The fear is that this could spread to other bacteria and create the bacterium that would be resistant to everything,” stated Dr. Beth Bell, director of the Centers for Disease Control and Prevention’s National Center for Emerging and Zoonotic Infectious Diseases.

As the Colistin-resistant  Escherichia coli was detected, the pharma industry has immediately called for cooperation among governments and companies to create incentives to revitalize research and development of new antibiotics. It is difficult to imagine a worse communication strategy. Now, even the most optimistic and confident consumer will suspect a hidden agenda behind the super bug  alarm.

It is probably true that there are too few antibiotics under development today, but we all know that the “super bug” threat cannot be met only- and chiefly -  by allocating more resources on pharma research. Colistin-resistant  strain of Escherichia coli were previously discovered in livestock in China and  in pig breeding farms in the US.  Although intensive farming is not the sole cause of antibiotics resistance, it is its major cause at global scale, and it is out of discussion that either we are able to address this cause, notably in Asia and China, or all our efforts to contain antibiotic resistance are destined to fail.

Finally, there is something morbid in the exceptionalism used by media to inform the public about this new “superbug”. When FORBES does not find a better way to describe  the discovery  of a Colistin-resistance bacterium in a clinical sample than saying that this discovery was  “like finding a vampire who is no longer affected by sunlight”, this is  probably a sign that something is going wrong in public health communication. 

Wednesday, May 25, 2016

The -arian epidemic

The solution to our epidemic of chronic disease starts with helping everyone understand the difference between real food and manufactured calories”, in such a way Roxanne B. Sukol - medical director of the Cleveland Clinic’s Wellness Enterprise – wisely concludes her articleWhy ‘healthy’ food is a bankrupt concept

Roxanne's articles deserves to be read together a  humorous  article on “Climatarian, vegavore, reducetarian: why we have so many words for cutting back on meat published by Kate Yoder in Vox. In her article, Kate describes the  -arian epidemic, a concept that she  borrows from Geoffrey Nunberg, a linguist at UC Berkeley, who wrote that -arian suffix has many uses but that the relevant meaning today is a "true believer in a cult or doctrine”. Kate amusingly draws the reader’s attention on the multiplications of – arian words in the description of our food choices. We increasingly live in a world (at least the affluent world) in which food choices have become a matter of identity, with different tribes facing each other with suspicion. 

The medical scene is not free from this bad habit.  The endless quarrel between supporters of “diets low in carbohydrates and high in fat”, “diets low in fat and rich in carbo”, “high protein regimes”, “whole food diets”, has been just revived by the update of the definition of "healthy food" recently issued by the US Food and Drug Administration and by the a recent report published in UK by the National Obesity Forum. This "war of diets" would be just ridiculous, if it were not also misleading and dangerous for consumers and patients. The point is much easier, we simply eat too much, while other world regions eat too less.

In this very moment more than 31 million people in southern Africa need urgently food because of one of the serious global food crisis of the last 25 years. The scale of the crisis unfolding in 10 or more southern African countries has shocked the United Nations, which says that the number of people threatened by starvation is expected to rise to at least 49 million by the end of 2016. Malawi, Mozambique, Lesotho, Zimbabwe, Namibia, Madagascar, Angola and Swaziland have already declared national emergencies or disasters, as have seven of South Africa’s nine provinces.  To this incoming crisis, one should add at least 12 million more hungry people in Ethiopia, 7 million in Yemen, 6 million in Southern Sudan and more in the Central African Republic and Chad. 

This might remind another period in which “Arian” words were in fashion. Ironically enough, the Nazi regime was obsessed by healthy foods, whole food diets, alimentary purity. Sometimes it comes to my mind the suspect that there could be  something more than merely ridiculous  in our exaggerated worries about food and diets, but most certainly it’s me to be too sensitive. 

Monday, May 23, 2016

ZIKA PANIC

Is Zika panic over? The question has been posed by Dominic Wilkinson, consultant Neonatologist and Director of Medical Ethics at Oxford University. Mr. Wilkinson explains with great clarity and intellectual honesty why the Zika alert in Brazil was probably overestimated. This does not imply that there is no risk at all, yet the shift in the public opinion from a “standard” epidemics of a dengue-like virus, to a global, impeding, catastrophe, was not probably dictated only by evidence. This shift was threatening to cause a cascade effect: suspending Brazil 2016 Olympic games had caused an economic disaster much more dangerous (also in public health terms) than the same Zika infection. If one wished to make a criticism to Mr. Wilkinson, one could just note that he failed to examine more in depth the various political implications of the emphasis on Zika infection in Brazil, which range from abortion legislation, to the Brazilian presidential crisis. Infectious outbreaks and epidemics have always been used also to do politics. Today they are used in a peculiar way, connected to globalization. I refer the reader to the seminal paper “SARS: Political Pathology of the First Post-Westphalian Pathogen, that David Fidler published in 2003 on The Journal of Law, Medicine & Ethics

This story remind us an important aspect of risk communication.  To explain it, I will use an example. I happened to have a friend who once decided to set himself up as an  arbiter elegentiarum. Actually, he had not that great taste for beauty, and most of his preferences were definitely a bit trivial. Yet, he discovered a perfect method to deceive his social environment: he became the “court cynic”.  Admiration, wonder, amazement, disappeared from his vocabulary. He started constantly laughing at anything. He became known for his sharp puns on virtually every artistic matter, and, admittedly, his mundane conversation was really brilliant. At the end, people accepted him as a recognized authority on matters of social behavior and taste. This is the same event that usually happens in risk communication. People use to considering negative predictions more accurate than positive ones. Pessimistic statements are easily seen as more “intelligent” and trustworthy, while overly optimistic statements are often perceived as they were a bit naïve and chiefly dictated by ignorance or by self-interest. Experts, including public health experts, are influenced by this phenomenon, and often they overstate negative facts because such an overstatement promise to give them some extra allure. Beware too pessimistic experts!