Tuesday, May 13, 2014

Should we get used to an age of compulsory confinement?

Here's my column from the Kingston Whig Standard of May 02/03 2014.

Yes, I know, Rob Ford went again on a drug-induced binge and blurted out his usual slew of racist, sexist, anti-gay views. He promised to disappear for four weeks and then return to save Torontonians tax monies, or something like that. I don’t live in that town, so whatever.
People elect the leaders they deserve. Also in Toronto, our premier was introducing her budget as I wrote this. Given that we live in a more or less bankrupt province, it is only mildly amusing that she reportedly found money to pay for infertile couples’ IVF procedures. Well, she didn’t quite “find” money, she decided to spend money that we don’t actually have. Her objective is to help those prospective parents who are unwilling to pay for IVF procedures themselves, but who seem wealthy enough to cough up the cash to raise children. Good going. We also learned this week, courtesy of the Supreme Court of Canada, that Prime Minister Stephen Harper and his friends in federal government seem to have only a very limited understanding of our constitutional arrangements, because they were yet again told off by the court.
Plenty to write a weekly column about, you might think. And yet, there are actually bigger fish to fry.The World Health Organization reported this week, in a disturbing document, the state of antimicrobial resistance across the world. We all have heard on and off about problems with the state of antibiotics research and development. A “race” was reportedly taking place. We were barely “ahead” of those nasty bugs. Typically, these problems seem to occur in faraway places like India and sub-Saharan Africa where tuberculosis is reportedly making a big comeback. Now comes the World Health Organization, telling us that the end is nigh. Well, not quite like that, but let this statement from the report’s foreword sink in for a moment: “Increasingly, governments around the world are beginning to pay attention to a problem so serious that it threatens the achievements of modern medicine. A post-antibiotic era — in which common infections and minor injuries can kill — far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century.” The signs are that we are losing the race, and it actually is a real race to stay ahead of bacteria that would — in the absence of antibiotics — kill us in very large numbers. Not just the poor in faraway places.
The World Health Organization report notes that multi-drug-resistant tuberculosis is probably significantly underreported, thereby undermining control efforts. It also warns that antibiotics-resistant bacteria causing common infections such as those of the urinary tract and pneumonia are becoming increasingly common across the world, not just in the tropics. You will be pleased to learn that just when the world is warming up and malaria-carrying mosquitoes are spreading into areas where they have not been seen before, artemisinin, the main component used to treat malaria sufferers, is not working well any longer in a number of countries. If the mosquitoes carrying the drug-resistant infection spread into other countries due to the changing climate, the malaria-related death toll could quickly rise. Even HIV drugs aren’t what they once were. At least one drug (of a limited number available) is failing between 10% to 17% of newly infected people because the virus has successfully developed resistance to that particular drug. Seemingly, like everything, even the things killing us evolve to get stronger and survive. The cost of treating people who have developed antimicrobial resistance to a whole host of bacteria, viruses, parasites and fungi is increasing rapidly. The side-effects of ever more complex treatment regimes mounted to preserve their lives are frequently significant. Resistance to anti-flu drugs is also increasing. This is a by and large unnecessary development, given that we could simply get vaccinated and so keep the number of flu infections down.
The really big problem, though, is antibacterial resistance and the lack of new treatments in our research and development pipeline. While the situation on the HIV frontiers might not be great, it thankfully takes a lot more effort to transmit HIV than it does to transmit tuberculosis or gonorrhea, for instance.
Talking about transmission, tuberculosis is fairly easily transmissible. You can pick it up without doing much about it, not much different from picking up the flu virus. You talk to someone with an active infection and that person might sneeze or cough, and voila, the odds aren’t terrible that you will become infected. Going forward, we will probably see more life-threatening illnesses that are easily transmissible and cannot be effectively treated any longer. The question arises how we should try to contain the spread of such illnesses.
We know already that many people who are aware of their infection and who understand that they carry an easily transmissible virus, tend to drag themselves into workplaces. More often than not, they aim to show that delivering at work while sick shows how professional they really are. The company comes first. Well, in the process, they pass their bug on to many other people who do the same, eventually a very large number of people are sick, some will die of an entirely avoidable infection. We are pretty good at being irresponsible in relation to our fellow citizens, especially when it comes to these sorts of infectious illnesses. Given that in the foreseeable future we will not be able to treat an increasing number of easily transmissible infections efficiently, if at all, I wonder whether it is time to begin a new conversation about our rules of conduct toward each other. Should we compel people with such infections to check into specialized facilities where they will be isolated and well cared for? It seems to me that would be a small price to pay to protect our public health. That is, assuming such a strategy could achieve its objective and prevent a significant number of new infections.
Udo Schuklenk teaches bioethics at Queen’s University, he tweets @schuklenk.

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