Book Review: Superbug

I hear a lot of doom and gloom when I'm listening to the news: wars, and rumors of wars, nuclear meltdowns, global warming, economic meltdowns. . . it's a lengthy and depressing list. But the longer I work at Large Nameless Agency and the more reading I do about the various pathogens out there that all cheerfully mutating towards greater and greater virulence, the more convinced I am that what's going to cause The End of Civilization as We Know It is going to be something a little more subtle, an apocalypse that will qualify as a whimper, not a bang. The doomsday question we all need to be addressing isn't how do we wean ourselves off fossil fuels or stop meddling in other nation's politics? It's what do we do when antibiotics stop working? Or, perhaps more accurately, what do we do collectively when we finally realize that's already happened?

I read a lot of scary stuff at work:  case studies of patients who die from exotic fungi that fill their lungs with furballs, for example, or have their brains eaten by amoeba, but none of those case studies ever made as much of an impression as the book Superbug.  A case here, a case there, and it doesn't really sink in, especially when, as Maryn McKenna notes, the medical community as a whole spent quite a few years in denial when it came to the issue of community-acquired methicillin resistant Staphylococcus aureus (MRSA) infections.

The journal I work for actually ran a review of Superbug back in October or so; I wasn't involved in the editing for it so didn't pay much attention to it at the time. I did recall that the reviewer wasn't too impressed with the book, said it was overly melodramatic and the author didn't understand the complexities of MRSA. Now that I've read the book, I understand the reviewer's hostility better. He should have declined to do the review -- his hospital is one that has a starring role in the book for using highly unsanitary practices on its obstetrics ward and for putting one of the patients profiled in the book through what can only be described as living hell. That particular hospital was also one that responded to the patient's concerns in sadly typical fashion: the infection didn't flare up until you were home, so you didn't catch it from us. The reviewer definitely, at least by association, falls into the group that McKenna is criticizing for doing too little, too late. 

Superbug is actually meticulously researched. McKenna names names -- doctors, hospitals, patients -- and it's pretty clear that some of the material being presented had the potential to generate lawsuits if the proper documentation didn't exist to back it all up. Clinicians and hospitals may be unhappy about some of McKenna's findings, but to call them "melodramatic" or unfounded is an exercise in wishful thinking. Someone being hospitalized repeatedly for an infection that won't go away and then finding out after the 7th or 8th hospitalization that the doctors had been using the absolutely wrong drug as part of the treatment regimen isn't melodrama -- it's tragedy. In example after example, patients come in with an infection and the physicians treat it empirically (i.e., they don't run lab tests to find out exactly what the bug is; they just treat the symptoms with drugs that have worked in the past for complaints that looked similar) (McKenna doesn't talk about why, but a lot of empirical treatment is insurance driven -- physicians are reluctant to order tests an insurance company won't pay for). So they start off with a type of penicillin. It doesn't work. So then they go for methicillin. It doesn't work. And they keep doing it, working their way up the chain to the most recent antibiotics in that same class of drugs -- and nothing works, but they don't want to admit they've been screwing up, especially when MRSA's been around for quite a few years now.

Bacteria mutate fast, and staph is no exception. Methicillin was developed fifty years ago because S. aureus became penicillin-resistant pretty quickly. Unfortunately, S. aureus than became methicillin-resistant. And resistant to a whole lot of other antibiotics that all worked on the same principle as either penicillin or methicillin. That was the bad news. The good news was that MRSA was rarely seen outside a hospital setting. If someone came down with a MRSA infection, they almost always picked it up in a hospital. That changed in the 1990s. Patients started popping up who didn't fit the profile. So what did the medical establishment do when confronted with the possibility of community-acquired MRSA? They ignored it. They pretended it couldn't be happening. The first few published reports describing MRSA happening outside hospitals were either discounted or ignored. It took several high profile outbreaks to get the medical community to really sit up and take notice -- but it may already be too late.

As McKenna tells us, not only has MRSA managed to evolve into multiple strains, some of which are incredibly virulent, with each new antibiotic tossed at it, seems to develop resistance faster. Even worse, the pharmaceutical companies have figured out there's not much money to made in antibiotics, so there aren't  many new ones under development. The big bucks for Big Pharma are in the drugs that people have to take for chronic conditions, like Lipitor for high cholesterol. Antibiotics are short term, a few weeks, a month, and the patient is done. Lipitor is forever.

In short, MRSA has evolved into a pathogen that's resistant to almost everything modern medicine can throw at it, the various strains are spreading (and in many cases how and why is a complete mystery to the epidemiologists), and there is no silver bullet waiting in the wings.

According to McKenna, and I tend to agree with her, we brought MRSA on ourselves. We've abused antibiotics, demanded them from our doctors to treat conditions that aren't treatable with antibiotics (like the common cold), taken them improperly (e.g., stopped taking them as soon as symptoms got better), allowed them to be dumped into the environment, and generally set up conditions that guaranteed they weren't going to be much use for very long. Along the way, we've also gotten remarkably careless about the things we used to do before we assumed there was a cure for everything, like handwashing. We went from figuring out germ theory to being fanatics about handwashing and strict hygiene in healthcare settings back to being remarkably careless in barely 100 years. We also engage in contradictory behaviors like spritzing kitchen counters with bleach while at the same time doing our laundry in cold water, so we're killing bacteria in one place while ignoring them in another.  

I'm not quite sure what the take-away message is in Superbug. You can't fool Mother Nature? Technology always has unintended consequences? We're fucked?