The Black Death Has Shut Down a City in China, and Struck 4 People in Colorado – and That’s Just This Month.

Yes, that Black Death, also known as The Bubonic Plague, or simply “the plague,” has hit Yumen, a city of about 30,000, in NW China this month. On 16 July it killed a 38 year old man and as a result health authorities had to quarantine 150 other people. They also sealed off Yumen by setting up police roadblocks around its perimeter, stopping people from going in or out. China Central Television announced that the city has enough rice, flour and oil to supply all its residents for up to one month.

This is the same plague that was responsible for one of the most devastating pandemics in human history, causing the deaths of an estimated 75 to 200 million people, peaking in Europe in the years 1346–53, killing 30–60% of its population and reducing the world population from an estimated 450 million down to 350–375 million. All of which explains China’s swift response.

Unfortunately, the plague has not been relegated to the history bin nor is it confined to northern China. In Eastern Colorado, for example, at the beginning of the month, 4 adults were infected by the plague. They are believed to have contracted it from a single source, a dog, who died from it.

Since 1957, 60 human cases of the plague have been identified in Colorado alone, and 9 were fatal. Although human cases occur infrequently, the plague is severe and potentially life-threatening if not quickly treated with antibiotics.

The following graphics show us the extent of the problem at home and abroad:

So both the good news and the bad news is the same: antibiotics are needed to treat bacterial-based diseases such as the plague. The reason this is bad news is that our world leaders in health — e.g., the World Health Organization, the US Centers for Disease Control and Prevention, the New England Journal of Medicine — have sounded the alarm on the growing global crisis of antibiotics resistance. The Lancet puts it this way: “[W]e are at the dawn of a post antibiotic era,” with “almost all disease-causing bacteria resistant to the antibiotics commonly used to treat them. In other words, antibiotic-resistant bacteria, like the proverbial time bomb, are poised to wreak infectious havoc on a worldwide scale.

The global nature of the pathogen problem can be seen in the graphic below. Notice, though, it under-represents the problem because, for example, it doesn’t include current or recent epidemics such as C. difficile and MRSA in the US, Ebola in West Africa, not to mention the recent appearance of the plague.

Now imagine life without antibiotics – what then? Scientists warn us that even the 14th century plague bacterium could develop drug-resistance and become a major health threat. In 1995, for example – before the global development of antibiotic resistance – a new multi-drug-resistant form of the plague was found in a 16-year-old boy in Madagascar. The strain developed resistance to 8 antibiotics including streptomycin and tetracycline.

We don’t know which one (or more) of the multitude of microbes that live among us will develop resistance and become a runaway pathogen: who, for example, would have ever guessed the plague pathogen?

What the authorities are telling us, however, is that our 70 year old antibiotic shield has been permanently pierced. Leading organizations such as the Harvard School of Public Health also agree on the one thing above all else that we, the people, need to do: it is this.

Get Ready for the Sea Change in how we Think About Our Microbes and Therefore How We Treat Infectious Disease

Every so often someone comes around that changes the rules of the game, changes the very way in which we think about a subject. In medicine, in the world of bacteria, antibiotics, and the global crisis of antibiotic resistance, that person is the impeccably-qualified clinician-researcher Brad Spellberg, MD, Chief Medical Officer, Los Angeles County and University of Southern California. This is a man who possesses a unique blend of experience, youth and energy, and professional heft. In other words, he is not a dreamer, he’s a visionary, and he and the colleagues he runs with are on the leading edge of thought that I hope will transform infectious disease medicine, and more.

Excerpted below is what he said earlier this year during a panel discussion at an Institute of Medicine seminar, “Antimicrobial Resistance: A Problem Without Borders.” As you read what he has to say keep in mind that biological principles generalize, not just across organisms but also across species, up to and including the “highest” ones. What he says about the needed paradigm shift from one of war to one of peaceful coexistence is profound. And it took him all of 2 minutes to say it:

Brad SpellbergI like to go back to first principles before I tackle complex problems. This whole thing about winning the war against microbes … nah!

We’re not going to win a war against organisms that outnumber us by a factor of 1022 , outweigh us by a hundred million-fold, replicate 500,000 times faster than we do, and have been doing this for 10,000 times longer than our species has existed!

So what we need to do is flip it around. We’re not at war with them. What we need to do is, in the immortal words of Dave Gilbert, achieve peaceful coexistence. The question is, what strategy do we deploy to achieve peaceful coexistence?

I think we need to start thinking of infections, by and large, in most cases, as accidents. There is no advantage for bacteria in most cases to infect us. They are much better off being non-infectious commensals in our gut.

In some cases we do have to have treatment to remove them from where they’re not needed. That may be antibiotics, it may be phages [viruses that target pathogenic bacteria], it may be single pathogen therapies, it may be immune enhancers; it’s all of the above: there isn’t going to be a single strategy. We need to relieve the pressure on any one strategy so that they can’t immediately adapt to that strategy. And I really do think that in the future we will be increasingly treating infections by a combination of targeted therapies; targeted to the bug, and therapies targeted to the host. It is the host inflammatory response that does cause the majority of signs and symptoms of infections that patients experience.

Moderator, Harvey Fineberg, MD, PhD, President, Institute of Medicine:  That’s a very interesting turnabout in thinking about the microbial world in which we coexist as the natural arrangement; and, our job in a sense is to figure out how we coexist, peacefully, as you put it.

It does invert the usual way we think about, if you will, the war metaphors of invasion, defense, and, if you will, destroying the enemy.

Brad Spellberg: Absolutely.

Harvey Fineberg: So it does reverse things.

Further exposition of Brad Spellberg’s thinking can be found here, at the New England Journal of Medicine; and a useful backgrounder about the new understanding of our bacteria and us – yes, we’re a team – is this popular essay, recently published in the New York Times.

Here is the panel discussion:

Is MRSA a Security Threat?

The conventional security threat.

If you’re a writer or a filmmaker in search of a fresh storyline then look no further than the 172 page thought-packed report just released by Britain’s Ministry of Defence, “Global Strategic Trends – Out to 2045,” which warns us of emerging security threats over the next 30 years.

It features our usual suspects: climate change driving millions from coastlines creating havoc, and the increasing threat of cyber-attack as information and communication goes digital. Trending upwards, for example, are the rise of robots, drones and corporate armies, e.g., Blackwater, that will change how we do war, and; as a predicted 3.9 billion people are likely to suffer water shortages, it will replace, or complement, oil, as a primary cause of global conflict.

Then we’re introduced to the new kid on the block: for the first time in its 5 year reporting history the MoD lists antibiotic-resistant pathogens as a “security threat.” The reason is two-fold. First, as antibiotics are rendered useless, infections caused by battlefield wounds will result in more lost lives and limbs than is the case now.

Second, and more compelling, is the effect of the anticipated combination of 4 events: (1) an increase in world population from the current 7.2 billion to 10 billion, (2) the fact that the fastest growing segment of the population will be the elderly – the number of people over 60 will be 2 billion in 30 years, representing a quarter of the globe’s population, (3) urbanization – by 2045, the proportion of people living in cities will increase from the current 50% to around 70% of the world’s population, and (4) poverty – 1 billion people throughout the world already live in slums, lacking basic amenities, and there could be almost 3 billion people living in these conditions by 2045.

The best economic evidence we have says inequality is rising to unprecedented levels, especially in the United States. The MoD report says if we don’t handle the coming economic and demographic shift properly the result will be the overcrowding of a vast and vulnerable (elderly & poor) population. That, in turn, will drive an increase in communicable disease where “social unrest or even violence could ensue.”

The emerging security threat: The enemy within - a million of these guys fit on the head of a pin but they kill & wound us more than our recent wars have.

But if framing infectious disease as a security threat is where we’re headed, take a look at where we are right now using just 1 disease-causing microbe, MRSA, as a case study. In the US alone it kills at least 11,000 people a year and blinds, amputates, and disfigures, etc. more than 80,000. Compare those numbers to a known and conventional security threat, the Vietnam War. Over its 20 year history ending in 1975 it killed roughly 3,000 US military members a year and blinded, amputated, and disfigured, etc. just over 7,500 more.

And that’s just a comparison to MRSA. All known antibiotic-resistant pathogens in the US result in about 23,000 killed and 2 million wounded every year. Over a 20 year period, that’s 460,000 dead and 40 million injured. The Vietnam totals are 58,300 dead and just over 150,000 wounded.

So here’s the question. If you are wounded or dying does it matter whether the cause is bullets or bacteria? We can even take it one step further. If a security threat infiltrated the US killing and wounding 23,000 and 2 million people respectively, every year, we would call that domestic terrorism and we would be living under a state of emergency. So looking at the current infectious disease carnage in this way, and given that the British Ministry of Defence is framing the rising global crisis of antibiotic resistance as a coming “security threat,” why aren’t we calling it that right now?

Do the Right Thing

Margaret Riley, Ph.D.: When we use an antibiotic it is like using an H-bomb because we are decimating the majority of our body’s microbial cells. Antibiotics are not “smart bombs,” they’re indiscriminate killers.

We expect a lot from our doctors. So when something comes along telling us they’re not doing what they should, it’s both surprising and disappointing.

Such was the case 2 weeks ago with the release of a survey that found that doctors prescribe antibiotics even when they shouldn’t, and do so for reasons that are highly questionable. For example, 28% of doctors will give an antibiotic simply because the patient asks for one, and 15% will prescribe them out of malpractice concerns – yikes!

But it’s another finding that’s even more worrisome: 11% of clinicians say their reason for prescribing an antibiotic when it’s not indicated is that, well, it won’t cause any harm and, besides, maybe it will do some good, perhaps in the way that a placebo will.

Oops. The problem with this “it will do no harm” school of thought is that it’s not only flat-out wrong, it’s also dangerous.

So says Margaret Riley, Ph.D., professor of biology at the University of Massachusetts, Amherst. She analogizes the taking of antibiotics to the ingestion of a hydrogen bomb on the basis that it kills everything, all of your body’s bacteria, the good and the bad. Antibiotics, she says, are not like a laser-guided missile that kill only the bad bacterial cells. Sound familiar? Think cancer.

Because in this sense, the effect on your body of a course of antibiotics is similar to the effect of a course of radiation to treat cancer: in both cases you’re using a shotgun to kill a fly and so you end up with “collateral damage,” examples of which are well-known in the case of radiation therapy – hair loss, fatigue, decreased appetite, radiation sickness, and so on.

The collateral damage caused by inappropriately prescribed antibiotics puts patients at risk for allergic reactions, super-resistant infections, and deadly diarrhea caused by Clostridium difficile, according to the US Centers for Disease Control and Prevention.

But remember, at least with radiation treatment there are cancer cells to be destroyed. But what this survey is saying is there are no disease-causing bacterial cells around to kill – but nevertheless 11% of clinicians write these collateral-damage-inducing scripts for antibiotics on the basis that, in their misguided view, it does no harm.

One more thing: it’s this over-prescription of antibiotics that drives the growing global crisis of antibiotic resistance. A problem so severe that even the Prime Minister of Great Britain, David Cameron, got on board this month publicly warning us that “We are in danger of going back to the dark ages of medicine to see infections that were treatable not be treatable and we would see many thousands of people potentially die from these infections.”

So back to our survey. The explanation for the physician-poor result, according to Russell Steele, MD, head of pediatric infectious diseases at the Ochsner Health Center for Children in New Orleans, Louisiana, is that “Education wears off in 5 years.” Residents and interns, he says, get it right when it comes to prescribing antibiotics, “but once they’re out in practice, they start sliding, and use antibiotics indiscriminately.”

Okay, that’s a start. And while we may appreciate this honest admission of indiscriminate use of antibiotics by physicians, on this critical issue at least, we expect more from our doctors – we expect them to do the right thing.

Here is Dr. Margaret Riley’s interesting (she has puppets!) lecture:

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