Download Mini-Lecture

Mini-Lecture
© Robert J. Brym (2004)
#6
The Social Limits of Modern Medicine
Around February 5th, 2003, a 64-year-old professor of medicine from Guangzhou, the capital
of Guangdong Province in South China, came down with an unidentified respiratory ailment. It
did not bother him enough to cancel a planned trip to Hong Kong, so on February 12th he checked
into that city’s Metropole Hotel. Ironically, as it turned out, the desk clerk assigned him room
911. Other 9th floor guests included an elderly couple from Toronto and three young women from
Singapore. All of these people, along with a local resident who visited the hotel during this
period, fell ill between February 15th and 27th with the same respiratory ailment as the professor.
The professor died on March 4th. The Canadian woman returned to Toronto on February 23rd and
died at her home on March 5th. The eventual diagnosis: Severe Acute Respiratory Syndrome, or
SARS, a new (and in 9% of cases, deadly) pneumonia-like illness for which there is no vaccine
and no cure.
SARS originated in Guangdong Province. By June 12th, 8,445 cases of SARS had been
identified in 29 countries and 790 people had died of the disease. Quickly and efficiently, global
travel spread HIV/AIDS, West Nile Virus, and now SARS from remote and isolated locales to the
world’s capitals. The United Nations has labeled Toronto the world’s most multicultural city. It
has a large Chinese population, mainly from Hong Kong. It is therefore not surprising that,
outside of China, Hong Kong, and Taiwan, Toronto became the world’s number one SARS hot
spot.
Once identified as a potential SARS case, a person is quarantined at home for ten days.
However, if people exhibit symptoms of the disease, they go to a poorly ventilated institution
where the air is maintained at a constant warm temperature that is ideal for the multiplication of
germs. In this institution, many young and elderly people with weakened immune systems
congregate. A steady stream of germs pours in round the clock. Staff members too often fail to
follow elementary principles of good hygiene. That institution is a hospital. There, germs spread.
Most of the 238 people in Toronto who caught SARS as of June 12th, 2003 did so in hospital
before stringent isolation and disinfection procedures were imposed.
The characterization of hospitals as ideal environments for the spread of germs may seem
harsh. It is not. In fact, among the world’s rich countries, the hospital system in the United States
is perhaps the most dangerous in this respect, although Canada is not far behind. The Chicago
Tribune published a major investigative report on the problem in 2002. Adopting the same
methods used by epidemiologists, the Tribune analyzed records from 75 federal and state
agencies. It also examined hospital files, patient databases, and court cases to produce the most
comprehensive analysis of preventable patient deaths linked to infections in 5,810 hospitals
nationwide. It found that of the 35 million Americans admitted to hospital each year, about 6%
contract a hospital-acquired infection such as pneumonia, influenza or staphylococcus. In 2000,
an estimated 103,000 people died due to hospital infections. (The Centers for Disease Control
estimated 90,000 such deaths in 2000, but their research extrapolated from just 315 hospitals.) If
the government classified death due to hospital infection, it would be the fourth leading cause of
death in the nation, behind heart disease, cancer, and stroke. The Tribune identified about a
quarter of hospital infection deaths as non-preventable because they resulted from problems that
had not been detected beforehand by state, federal or health-care investigators. That leaves 75,000
preventable deaths, caused by problems investigators had already identified. These deaths could
have been avoided if we kept hospital rooms and operating theaters cleaner, sterilized all
instruments after use, fixed ventilation problems, routinely flushed water pipes, ensured that all
doctors and nurses disinfect their hands after examining each patient, and so forth.
Cutting costs and catering to paying customers are among the chief means of keeping
shareholders happy in a health care system driven chiefly by profitability. This means investing
disproportionately in expensive, high-tech, cutting-edge diagnostic equipment and treatment for
those who can afford it. It also means scrimping on simple, labor-intensive, time-consuming,
hygiene for those who cannot. About a third of all hospitals in the United States are operating at a
loss and a third are on the edge of bankruptcy according to the American Hospital Association.
Particularly in hospitals in financial distress, cleaning staffs are too small and insufficiently
trained. Nurses are too few. According to research by the Harvard School of Public Health, these
are the kinds of factors correlated with hospital-acquired infections. As San Francisco registered
nurse Trande Phillips says: “When you have less time to save lives, do you take 30 seconds to
wash your hands? When you’re speeding up you have to cut corners. We don’t always wash our
hands. I’m not saying it’s right, but you’ve got to deal with reality.”
This was not always the reality. From the 1860s to the 1940s, American hospital staffs were
obsessed with cleanliness. They had to be. In the era before the widespread use of penicillin and
antibiotics, infection often meant death. In the 1950s, however, the prevention of infections in
hospitals became less of a priority because penicillin and antibiotics became widely available. It
was less expensive to wait until a patient got sick and then respond to symptoms by prescribing
drugs than preventing the sickness in the first place. Doctors and nurses have grown lax about
hygiene over the past half-century. For example, the Chicago Tribune investigators found a dozen
recent health care studies showing that about half of doctors and nurses do not disinfect their
hands between patients.
Using penicillin and antibiotics indiscriminately has its own costs. When living organisms
encounter a deadly threat, only the few mutations that are strong enough to resist the threat
survive and go on to reproduce. Accordingly, if you use a lot of penicillin and antibiotics, “super
germs” that are resistant to these drugs multiply. This is just what has happened. Penicillin could
kill nearly all staphylococcus germs in the 1940s but by 1982 it was effective in fewer than 10%
of cases. In the 1970s, doctors turned to the more powerful methicillin, which in 1974 could kill
98% of staphylococcus germs. By the mid-1990s, it could kill only about 50%. It has thus come
about that various strains of drug-resistant germs now cause pneumonia, blood poisoning,
tuberculosis, and other infectious diseases. Drug-resistant germs that could formerly survive only
in the friendly hospital environment have now adapted to the harsher environment outside the
hospital walls. Pharmaceutical companies are racing to create new antibiotics to fight drugresistant bugs but germs mutate so quickly our arsenal is shrinking.
The epidemic of infectious diseases caused by slack hospital hygiene and the overuse of
antibiotics suggests that social circumstances constrain the success of modern medicine. It is
difficult to see how we can solve these problems without setting up a government watchdog to
oversee and enforce strict rules regarding hospital disinfection. That would require considerable
tax money and it would impose a principle other than profitability on the health care system.
Therefore, it would be a political hot potato.