Healthcare, medicine & pharmaceuticals

Are we resistant to antibiotic resistance?

In “The germ of a new idea”, last issue, we wrote the average American has had 10-20 courses of antibiotics by the age of 18. About 75% of this dose comes from eating animals fed antibiotics to speed up their growth. Is it any wonder, then, that serious diseases are becoming resistant to antibiotics and there is an “apocalyptic” threat to our health? Dame Sally Davies, chief medical officer (UK), says this is so serious, it should be added to the national risk register of civil emergencies. The risk register for 2013 includes a deadly flu outbreak, catastrophic terrorism and major flooding.

Drug resistance is not new. When patients do not take a full course of antibiotics, the more resilient strains are allowed to multiply. One of the worst cases is the hospital superbug, MRSA, but others include tuberculosis and gonorrhea. Some 80% of gonorrhea cases are resistant to tetracycline. Worse, carbapenems, which are used for the most serious infections of all, are losing their potency – three cases of resistant bacteria were detected in 2003, with 333 in 2010 and 217 cases in the first six months of 2011.

Another problem is over-prescription of antibiotics, even for viruses, where they are known to be ineffective. Some of this is initiated by GPs; some is demanded by patients who just want a drug.

Big Pharma has lost interest in researching antibiotics further, because they are used so sparingly compared to drugs for chronic diseases, such as diabetes or heart conditions, which need to be taken everyday for a lifetime. So even when researchers make useful discoveries, the drug companies are not willing to invest in them.

The best way to handle this, according to regulatory agencies, medical bodies and big pharma, is to disconnect profits from the volume of drugs sold. This can be done by adjusting patent rights or offering incentives for innovation, and has already been done with other drugs. It seems remarkable that such a potentially devastating problem has received so little funding. Perhaps when more (1st world, educated) people start to die of once-treatable infections, antibiotic resistance will get the attention it deserves.

The unbearable weight of obesity

In many cultures, such as Morocco and Mauritania, obesity is valued as a sign of wealth and being thin is a sign of poverty. In the affluent West, obesity can certainly be a sign of wealth, but it also points to something gone very wrong indeed with our way of life. Growing rates of obesity, and its insidious effects on public health and demand on health budgets, are creating a problem too gargantuan to be ignored.

The statistics speak for themselves: Two thirds of American adults are overweight and over one third are obese. America’s Institute of Medicine says people currently spend $150-190 billion a year on obesity-related illnesses. By 2030, nearly half could be obese and medical bills could top $US6.6 billion. Obesity rates worldwide almost doubled from 1980 to 2008. By 2030, the number of obese people worldwide may double to 3.3 billion. If everyone became as heavy as the average American, the world’s biomass would go up by 20%, as if 1 billion more people had been added.

Taking a macro view, this is one of the results of economic growth, not just in the West, but in countries that want what we have. It is all very well to want a car, but it is much healthier for the body to ride a bicycle. Packaged goods, so often seen as a sign of affluence, offer the body less nutrition, more fat, and much more sugar. Add to this the power of marketing, and obesity becomes a worldwide problem.

The evolutionary view is that humans are disposed to hold on to weight, rather than let it go. If someone loses weight, the body works hard to get it back; if they put on weight, the body has no defence. Thanks to leptin, a hormone secreted by fatty tissue, we know when it is time to stop eating. But when we consume too much sugar over time, the brain changes its response. Fatter people become just as excited by the sight of sugary food, but release less dopamine, the pleasure hormone, so they feel less satisfied. If they start to lose weight, leptin levels drop and they feel they are starving.

Our story, Slim chance of losing weight, explored some diet drugs being prescribed at the time. Unfortunately, regulators have banned more diet drugs than they have approved. It seems the drugs available are heavy with side effects and still only offer minimal weight loss. One drastic measure is bariatric surgery, where surgeons insert a gastric band around the top part of the stomach, forcing the patient to eat much less or feel uncomfortably full. This has its own problems, but can lead to more weight loss over time – up to 28% - than diet drugs combined with exercise – 5-10%. Fewer of these operations are being done in America, probably because insurance companies do not like paying for them.

Obesity brings other health problems along with it, including high blood pressure and blood sugar levels, high cholesterol and fats in the blood, and chronically inflamed organs. It also interferes with insulin metabolism, causing another massive epidemic – diabetes. The WHO says excess fat is responsible for 44% of cases of diabetes, 23% of ischaemic (blocked tube) heart disease and over 40% of some cancers.

The diabetes market is currently worth $US35 billion and could reach $US58 billion by 2018. By 2030, for example, there could be 130 million diabetics in China, so Novo Nordisk is “training” doctors in China so they too will prescribe its diabetes drugs.

But it won’t be much fun for the governments that are subsidising the cost of these drugs to treat diabetes. Meanwhile, citizens with all the other obesity-induced chronic diseases, need to take pharmaceutical drugs every day for the rest of their lives. The bill for that will be outrageously unsustainable. It’s not too gross for Big Sugar either. Sales of packaged goods have nearly doubled to $US2.2 trillion this year, thanks to increasing appetites in Brazil, China and Russia. Soft drink sales more than doubled in ten years to $US532 billion, thanks to quadruple increases in India, Brazil and China. Yum! Brands, which owns KFC, Pizza Hut and Taco Bell, earns 60% of its profit from the developing world. That is only the beginning given there are 58 restaurants for every 1 million Americans, compared to only two restaurants per million in the developing countries.

The food industry is three times the size of the tobacco industry, so what is to be done? It is important to understand that it’s not all the fault of corporations: people want to eat sugary, processed food. Euromonitor says sales of “better-for-you” food (less sugar, fat, salt) were only 7% of drink and packaged food sales last year. When PepsiCo decided not to advertise sugary drinks during the Super Bowl, shareholders forced them to reconsider.

Is the answer a nanny state, telling people what to eat, taxing sugary food, removing corn subsidies, changing food labeling, or “nudging” citizens to change by making healthy food less expensive? Should corporations be made accountable, or is it up to the individual to ask for something different? Any way you look at it, it’s a weighty decision.

Healthcare that doesn’t cost a bundle

In America, unpaid medical bills are the main causes of bankruptcies, affecting nearly 2 million people in 2013. One reason is because the current approach to healthcare is so complex, unwieldly, and unnecessarily expensive. For example, someone with chronic knee pain must go to five different facilities – GP for referral, orthopedist for diagnosis, MRI provider for scan, hospital for operation (with a suite of specialists) and physiotherapist for rehab. Each one must be paid.

It is the same old story: the system favours the providers and nobody cares about the experience of the patient. Patients are essentially passive receivers of “care”. A new model, “bundled healthcare”, proposes that there is one set price for the whole process, with no extras. If there are any difficulties, they can be fixed without extra charge. Hospitals, doctors, employers and insurers would work together to make the patient’s experience more friendly and streamlined. This is a change from a la carte to a prix fixe menu – with better results.

One hospital in Massachusetts found a knee replacement bundle resulted in fewer complications and fewer hospital readmissions, pushing their costs down. A hospital in Pennsylvania launched a coronary bypass bundle and post-op infections fell 63%, total costs dropped 5% and hospital profits (let’s not forget those) rose by $US2,000 per case. It sounds like a win/win for patients and hospitals.

In the 1990s, Michael Porter of Booz-Allen argued that hospital and doctors should move away from services to clinical products, and bundled healthcare is a result of that. The knee replacement bundle becomes a product rather than a series of expensive services where each service involves a new patient form and lack of continuity. It also allows for continuous improvement, the manufacturing concept, as the bundle is repeatedly tested and refined. The existence of electronic health records and information exchange also allows this kind of new healthcare to work.

Attitudes to bundled healthcare vary depending on who you talk to. Patients are keen to save money and be better informed along the way. Large hospitals are more open to it than smaller ones, as they are more likely to have the resources to try something new. Insurers, on the other hand, were skeptical. Perhaps they viewed negatively the level of coordination they would need, with hundreds of employers and dozens of providers. Ultimately, the insurers need to support it.

Why your gut is the second brain

It’s intuitive that you think with your gut, or have a “gut reaction”, but science tells us that it’s true. We have a so-called “second brain”, a separate nervous system (ENS) with 500 million neurons (the brain has 85 billion) and it is 9 metres long, from oesophagus to anus. Of course, it controls digestion, but it also plays a crucial, subconscious role in physical and mental wellbeing.

The second brain needs so many neurons because it is responsible for keeping out invaders in the food. For example, it can trigger diarrhoea or vomiting or both. Both fear and stress can trigger these same responses, such as “butterflies” in the stomach before a performance. It also produces 50% of all dopamine (pleasure hormone) and 95% of all seratonin (the feel-good molecule) – the other brain does the rest. The ENS is crucial for preventing depression, regulating sleep and appetite, and repairing damaged cells in the liver and lungs. One scientist believes the gut even has memory, but this is not supported.

Knowledge of the second brain has stimulated research into Alzheimer’s, as the plaques found in the brain are present in neurons in the gut too. Autistic people also have GIT problems. In fact, a gut infection or extreme stress in a baby’s early years may lead to irritable bowel syndrome later in life. Scientists can theoretically use gut biopsies to make early diagnosis of these conditions. It may also be possible to harvest neutral stem cells from the gut, rather than from the more tricky brain or spinal cord.

It appears a healthy gut is much more than a consumer and processor of food and drink. A better understanding of the second brain may help deal with the growing problems of obesity and diabetes as well as depression, Alzheimer’s and Parkinson’s.

Brain mapping

Mapping the world may seem like a gargantuan task, but mapping the human brain is just as daunting. Scientists are as keen to learn about the brain as astronauts are to know what is out there in space. Governments are behind them: Obama is backing the Brain Activity Map (BAM) to the tune of $US3 billion and the EU is backing the Human Brain Project, for Euros 1 billion. Mapping will involve a massive collaboration of experts, from biochemists and psychologists to geneticists and computing boffins.

During the 1990s, scientists discovered neural plasticity, the ability of the brain to adapt to injury or disease, and the scanning technique, magnetic resonance imaging (MRI). But neither of these provided the answer to many mental illnesses. Half the world suffers from some kind of condition affecting the brain, such as autism or Parkinson’s or depression, and a map of the human brain could help develop treatments for these debilitating conditions.

Both the US and EU will focus on the “connectome”, the chemical and electrical connections between the 100 billion neurons and 10,000 others in the brain. The US Human Connectome Project will examine slices of brain under electron microscopes and scan the brains of volunteers while they perform cognitive tests.

The Blue Brain Project in Switzerland will simulate neural circuitry on a computer, by feeding in information from real brains into a virtual brain. Machines based on brain circuitry are called “neuromorphic”. Future machines will have a standard digital processor and a neuromorphic processor, because the neuromorphic ones work with less energy and are more reliable.

The use of implanted electrodes for patients who are very ill is not so pleasant for volunteers involved in furthering neuroscience. “Tattoo electronics” provides a non-invasive method of picking up neural activity from outside the skull using flexible silicon circuitry, rather than putting electrodes on the skull. Another approach is to grow and study neurons in a lab, by transforming stem cells into neurons.