The Best American Science and Nature Writing 2014 (33 page)

Before antibiotics, five women died out of every one thousand who gave birth. One out of nine people who got a skin infection died, even from something as simple as a scrape or an insect bite. Three out of ten people who contracted pneumonia died from it. Ear infections caused deafness; sore throats were followed by heart failure. In a post-antibiotic era, would you mess around with power tools? Let your kid climb a tree? Have another child?

“Right now, if you want to be a sharp-looking hipster and get a tattoo, you're not putting your life on the line,” says the CDC's Bell. “Botox injections, liposuction, those become possibly life-threatening. Even driving to work: we rely on antibiotics to make a major accident something we can get through, as opposed to a death sentence.”

Bell's prediction is a hypothesis for now—but infections that resist even powerful antibiotics have already entered everyday life. Dozens of college and professional athletes, most recently Lawrence Tynes of the Tampa Bay Buccaneers, have lost playing time or entire seasons to infections with drug-resistant staph, MRSA. Girls who sought permanent-makeup tattoos have lost their eyebrows after getting infections. Last year three members of a Maryland family—an elderly woman and two adult children—died of resistant pneumonia that took hold after simple cases of flu.

At UCLA, Spellberg treated a woman with what appeared to be an everyday urinary tract infection—except that it was not quelled by the first round of antibiotics, or the second. By the time he saw her, she was in septic shock, and the infection had destroyed the bones in her spine. A last-ditch course of the only remaining antibiotic saved her life, but she lost the use of her legs. “This is what we're in danger of,” he says. “People who are living normal lives who develop almost untreatable infections.”

In 2009 Tom Dukes—a fifty-four-year-old inline skater and bodybuilder—developed diverticulosis, a common problem in which pouches develop in the wall of the intestine. He was coping with it, watching his diet and monitoring himself for symptoms, when searing cramps doubled him over and sent him to urgent care. One of the thin-walled pouches had torn open and dumped gut bacteria into his abdomen—but for reasons no one could explain, what should have been normal
E. coli
were instead highly drug-resistant. Doctors excised 8 inches of his colon in emergency surgery. Over several months, Dukes recovered with the aid of last-resort antibiotics, delivered intravenously. For years afterward, he was exhausted and in pain. “I was living my life, a really healthy life,” he says. “It never dawned on me that this could happen.”

Dukes believes, though he has no evidence, that the bacteria in his gut became drug-resistant because he ate meat from animals raised with routine antibiotic use. That would not be difficult: most meat in the United States is grown that way. To varying degrees, depending on their size and age, cattle, pigs, and chickens—and, in other countries, fish and shrimp—receive regular doses to speed their growth, increase their weight, and protect them from disease. Out of all the antibiotics sold in the United States each year, 80 percent by weight are used in agriculture, primarily to fatten animals and protect them from the conditions in which they are raised.

A growing body of scientific research links antibiotic use in animals to the emergence of antibiotic-resistant bacteria: in the animals' own guts, in the manure that farmers use on crops or store on their land, and in human illnesses as well. Resistant bacteria move from animals to humans in groundwater and dust, on flies, and via the meat those animals get turned into.

An annual survey of retail meat conducted by the Food and Drug Administration—part of a larger project involving the CDC and the U.S. Department of Agriculture that examines animals, meat, and human illness—finds resistant organisms every year. In its 2011 report, published last February, the FDA found (among many other results) that 65 percent of chicken breasts and 44 percent of ground beef carried bacteria resistant to tetracycline, and 11 percent of pork chops carried bacteria resistant to five classes of drugs. Meat transports those bacteria into your kitchen, if you do not handle it very carefully, and into your body if it is not thoroughly cooked—and resistant infections result.

Researchers and activists have tried for decades to get the FDA to rein in farm overuse of antibiotics, mostly without success. The agency attempted in the 1970s to control agricultural use by revoking authorization for penicillin and tetracycline to be used as “growth promoters,” but that effort never moved forward. Agriculture and the veterinary pharmaceutical industry pushed back, alleging that agricultural antibiotics have no demonstrable effect on human health.

Few, though, have asked what multi-drug–resistant bacteria might mean for farm animals. Yet a post-antibiotic era imperils agriculture as much as it does medicine. In addition to growth promoters, livestock raising uses antibiotics to treat individual animals, as well as in routine dosing called “prevention and control” that protects whole herds. If antibiotics became useless, then animals would suffer: individual illnesses could not be treated, and if the crowded conditions in which most meat animals are raised were not changed, more diseases would spread.

But if the loss of antibiotics changes how livestock are raised, then farmers might be the ones to suffer. Other methods for protecting animals from disease—enlarging barns, cutting down on crowding, and delaying weaning so that immune systems have more time to develop—would be expensive to implement, and agriculture's profit margins are already thin. In 2002 economists for the National Pork Producers Council estimated that removing antibiotics from hog raising would force farmers to spend $4.50 more per pig, a cost that would be passed on to consumers.

H. Morgan Scott, a veterinary epidemiologist at Kansas State University, unpacked for me how antibiotics are used to control a major cattle illness, bovine respiratory disease. “If a rancher decides to wean their calves right off the cow in the fall and ship them, that's a risky process for the calf, and one of the things that permits that to continue is antibiotics,” he said, adding, “If those antibiotics weren't available, either people would pay a much lower price for those same calves, or the rancher might retain them through the winter” while paying extra to feed them. That is, without antibiotics, those farmers would face either lower revenues or higher costs.

Livestock raising isn't the only aspect of food production that relies on antibiotics or that would be threatened if the drugs no longer worked. The drugs are routinely used in fish and shrimp farming, particularly in Asia, to protect against bacteria that spread in the pools where seafood is raised—and as a result, the aquaculture industry is struggling with antibiotic-resistant fish diseases and searching for alternatives. In the United States, antibiotics are used to control fruit diseases, but those protections are breaking down too. Last year, streptomycin-resistant fire blight, which in 2000 nearly destroyed Michigan's apple and pear industry, appeared for the first time in orchards in upstate New York, which is (after Michigan) one of the most important apple-growing states. “Our growers have never seen this, and they aren't prepared for it,” says Herb Aldwinckle, a professor of plant pathology at Cornell University. “Our understanding is that there is one useful antibiotic left.”

 

Is a post-antibiotic era inevitable? Possibly not—but not without change.

In countries such as Denmark, Norway, and the Netherlands, government regulation of medical and agricultural antibiotic use has helped curb bacteria's rapid evolution toward untreatability. But the United States has never been willing to institute such controls, and the free-market alternative of asking physicians and consumers to use antibiotics conservatively has been tried for decades without much success. As has the long effort to reduce farm antibiotic use: the FDA will soon issue new rules for agriculture, but they will be contained in a voluntary “guidance to industry,” not a regulation with the force of law.

What might hold off the apocalypse for a while is more antibiotics—but first pharmaceutical companies will have to be lured back into a marketplace they have already deemed unrewarding. The need for new compounds could force the federal government to create drug-development incentives: patent extensions, for instance, or changes in the requirements for clinical trials. But whenever drug research revives, achieving a new compound takes at least ten years from concept to drugstore shelf. There will be no new drug to solve the problem soon—and given the relentlessness of bacterial evolution, none that can solve the problem forever. In the meantime, the medical industry is reviving the old-fashioned solution of rigorous hospital cleaning and also trying new ideas: building automatic scrutiny of prescriptions into computerized medical records and developing rapid tests to ensure that the drugs aren't prescribed when they are not needed. The threat of the end of antibiotics might even impel a reconsideration of phages, the individually brewed cocktails of viruses that were a mainstay of Soviet Union medical care during the Cold War. So far the FDA has allowed them into the U.S. market only as food-safety preparations, not as treatments for infections.

But for any of that to happen, the prospect of a post-antibiotic era has to be taken seriously, and those staring down the trend say that still seems unlikely. “Nobody relates to themselves lying in an ICU bed on a ventilator,” says Rice of Brown University. “And after it happens, they generally want to forget it.”

 

When I think of preventing this possible future, I reread my great-uncle's obit, weighing its old-fashioned language freighted with a small town's grief.

 

The world is made up of “average” people, and that is probably why editorials are not written about any one of them. Yet among these average people, who are not “great” in political, social, religious, economic or other specialized fields, there are sometimes those who stand out above the rest: stand out for qualities that are intangible, that we can't put our finger on.

Such a man was Joe McKenna, who died in the prime of life Friday. Joe was not one of the “greats.” Yet few men, probably, have been mourned by more of their neighbors—mourned sincerely, and sorrowfully—than this red-haired young man.

 

I run my cursor over the image of the tattered newsprint, the frayed creases betraying the years that someone carried the clipping around. I picture my cousin's grandmother flattening the fragile scrap as gently as if she were stroking her brother's hot forehead, and reading the praise she must have known by heart, and folding it closed again. I remember the few stories I heard from my father, of how Joe's death shattered his family, embittering my grandfather and turning their mother angry and cold.

I imagine what he might have thought—thirty years old, newly married, adored by his siblings, thrilled for the excitement of his job—if he had known that a few years later, his life could have been saved in hours. I think he would have marveled at antibiotics, and longed for them, and found our disrespect of them an enormous waste. As I do.

FROM
The Boston Globe Magazine

 

I
F YOU WERE GOING
to write down the most frightening infectious diseases you could think of, measles probably wouldn't be near the top of your list. Compared with the devastation of HIV/AIDS or the gruesome deaths caused by hemorrhagic fevers like Ebola, measles, with its four-day-long fevers and pervasive rashes, seems like nothing more than an annoyance.

But there is one thing that makes measles unique, and uniquely frightening to public health officials: it is the most infectious microbe in the world, with a transmission rate of around 90 percent. The fact that measles can live outside the human body for up to two hours makes a potential outbreak all the more menacing.

This explains the all-hands-on-deck response when officials with the Massachusetts Department of Public Health learned in late August that two unconnected patients—an infant who'd recently arrived in the United States and a foreign-born adult who'd recently traveled abroad—had visited area hospitals with active measles infections. Identifying the hundreds of people who'd potentially been exposed and then checking their vaccination status required, in the words of Dr. Larry Madoff, director of the state's Division of Epidemiology and Immunization, a “huge effort” on the part of dozens of state, local, and hospital employees.

Fortunately, there were no secondary infections this time around, a fact that is due in no small part to the impressive vaccine uptake rate in this state. It would be a mistake to assume this will always be the case: Massachusetts is seeing a surge in the number of unvaccinated children. Last year nearly 1,200 kids entered kindergarten with religious or philosophical vaccine exemptions, roughly double the total about a decade ago.

That mirrors what's happening across the country. What's so confounding is that many of the parents requesting exemptions for their children cite specious, disproven fears—such as that the vaccine could cause autism—many of which were based on a fraudulent, retracted study or fringe research published in non-peer-reviewed journals. And the rest of the country hasn't been as successful as Massachusetts in containing measles infections. Earlier this year, an intentionally unvaccinated seventeen-year-old from Brooklyn, New York, was infected with measles while on a trip to the United Kingdom. Because he lived in a community with a large number of other deliberately unvaccinated children, the virus quickly spread. By the time the outbreak was contained, fifty-eight people had been infected—making it the largest outbreak in the country in more than fifteen years. Nationwide, the Centers for Disease Control and Prevention reported 159 total cases between January and August, which puts 2013 on track to record the most domestic measles infections since the disease was declared eliminated from the United States in 2000.