- Machiavelli's Laboratory is a free ebook that I published on April 13, 2010. It is a satiric discourse on scientific ethics, from the perspective of an unethical scientist. Please don't take any of the advice and opinions in the book (or the excerpts featured in this blog) seriously.
This blog continues yesterday's blog on Man-Made Diseases."
In the first half of the twentieth century, three infectious diseases received the bulk of attention here in the U.S.: polio, syphilis, and tuberculosis. Every physician knew these diseases intimately. There were medical journals devoted exclusively to these diseases. Doctors specialized in these diseases and invented now-obscure names for their specific clinical presentations or variant forms (e.g., Pott's disease for tuberculosis of the spine; craniotabes for syphilis). Few of us today remember that polio was also called infantile paralysis and that its full name was poliomyelitis, or that it came in several clinical forms (e.g., bulbar polio, abortive polio).
In the mid-twentieth century, a cure for each of these diseases was discovered. Everyone was predicting that in a few years, polio, syphilis and tuberculosis would be eradicated. The predictions were accurate for polio, but they were somewhat off the mark for syphilis and wildly wrong for tuberculosis.
In the case of polio, prevention consisted of getting vaccinated. Syphilis was also easy. If you've had syphilis for less than a year, a single intramuscular injection of penicillin will cure you. Curing tuberculosis required some effort. For active cases of tuberculosis, patients were expected to swallow multiple pills, daily, for up to 18 months.
Basically, the reason that polio is virtually non-existent in developed countries, and the reason that you don't hear too much about syphilis these days, is that the cure comes in the form of one or two doses of a medication that the physician personally delivers in the office. The reason that tuberculosis is still a major public health problem is that it requires long-term treatment administered by patients.
Physicians understand, but do not always care, that patients simply do not adhere to long-term medication regimens. When groups of patients are closely monitored for medication compliance, nobody expects strict adherence to long-term therapy. Acceptable adherence is 80% compliance. But patients seldom meet acceptable levels of treatment. In a group of patients with hypercholesterolemia, only about half of the monitored group achieved 80% medication compliance for statins(1).
In the 1950s, when antiobiotics active against tuberculosis were discovered, everyone believed that this disease would soon be eradicated. They hadn't taken into account patient compliance. It was common for patients to stop their medication after a few weeks of treatment, or as soon as their symptoms abated. Not surprisingly, this practice gave the TB microbe (Mycobacterium tuberculosis) the opportunity to develop resistance to standard treatment. Within a generation, multidrug-resistant strains of tuberculosis emerged.
How did this play out in American cities? Baltimore is the home of Johns Hopkins Hospital, one of the most prestigious medical centers in the world. In Baltimore, Johns Hopkins employs more people than any other business. You would think that Baltimore would be the healthiest population in the world? It is not. In the 1970s, Baltimore had the highest tuberculosis rate of any city in the U.S. The incidence of new cases of active TB reported in Baltimore, in 1981, was 35.6 cases per 100,000 population (2). Baltimore hosts one of the greatest centers of health technology in the world, but physicians did not ensure that their TB patients followed their prescribed treatments.
The Baltimore City Health Department, in 1981, implemented directly observed therapy (DOT), a strategy wherein healthcare workers would routinely visit patients and watch them take their tuberculosis medications. The plan worked. In 2009, the incidence of TB in Baltimore was a mere 2.7/100,000 population (3). This is about 7.5% of the active TB incidence in 1981. The Public Health Department succeeded where the medical-industrial complex failed.
In the 1970s, tuberculosis re-emerged as a national health problem because the United States has a healthcare system that is disconnected from the realities that influence the incidence and severity of diseases. Currently, the healthcare system in the U.S. is faced with another, frightening, healthcare failure: the rise of new strains of staphylococcus and other common organisms that are resistant to currently available antibiotics. Like tuberculosis, antibiotic resistance arose in common organisms largely because treatment regimens were not followed to completion. Physicians worsened the problem by routinely prescribing antibiotics for people with viral syndromes (e.g. the common cold) that do not respond to antibiotics. Endogenous organisms, dwelling within those persons who receive inappropriate treatment with antibiotics, will develop resistance, over time. This is another example of a problem created by the medical-industrial complex. Like TB, the solution may come from the public health sector: making sure patients take the full treatment regimen for infections, insisting on scrupulous handwashing among hospital staff and thorough cleansing of patient rooms in clinics and hospitals. Low-tech methods, the same methods championed by Florence Nightingale (1820 - 1910), are the best weapons we have, at present, to fight drug-resistant pathogens.
It's funny the way things work out. The worse things become, disease-wise, the better things are for the medical-industrial complex. Emerging epidemics bring more patients, more severe diseases, more research funding, greater dependence on costly high-tech interventions (e.g., Intensive Care Units, non-generic antibiotics, genetic testing of microorganisms, scans, blood tests), and more revenue. The people who create public health problems are often the same people who benefit from the resulting havoc.
REFERENCES
[1] Briesacher BA, Andrade SE, Fouayzi H, Chan KA. Comparison of drug adherence rates among patients with seven different medical conditions. Pharmacotherapy 28:437-443, 2008.
[2] Chaulk CP, Moore-Rice K, Rizzo R, Chaisson RE. Eleven years of community-based directly observed therapy for tuberculosis. JAMA 274:945-951, 1995.
[3] Baltimore City Achieves Record Low Tuberculosis Case Rate as Health Department Launches Cutting-Edge Screening Program. Baltimore City Health Department (announcement) March 24, 2010.
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- © 2010 Jules Berman
key words: medical-industrial complex, American healthcare, physician reimbursement
