In the new millennium, the brutal reality of 225,000 iatrogenic deaths each year, a large percentage of which could be avoided by having physicians adhere to the hand washing and sterilization protocols that they themselves have designed, raises these questions:
Has the dominant mind-set changed since Holmes taught at Harvard Medical College?
How is it possible that physicians would not now be constantly demonstrating zealous and scrupulous personal adherence to established procedures and requirements for maintaining asepsis in hospital settings?
How can it be that the AMA is not insisting upon full and complete reporting of the incidence of nosocomial infections by every hospital in the nation?
How is it possible that physicians would not now be strenuously and loudly insisting on the fullest possible compliance by all hospital staff with existing aseptic procedures and infection control protocols?
The stubborn facts about the prevalence of nosocomial infection today demonstrate that American physicians continue to be extremely careless about their own infection control procedures, and that they remain disinclined to press hospital staff or administrators to make control of infection a high priority.
During the past two decades, over two hundred "peer-reviewed" studies or articles have been published in public health journals on infection control, infectious diseases, epidemiology, and microbiology including papers by evolutionary biologists setting out the catastrophic prospects for the public health if we continue along the present path, failing to require disciplined and consistent efforts by physicians and hospital staff members to rigorously control the spread of nosocomial infections. No references to any of these papers appear in the indices most commonly used by practicing physicians as guides for their continuing education. Medical library indexing patterns make it clear that in the most commonly used professional catalogs of scholarly papers there is no prominence being given to the shocking actuality that physicians and the people they supervise are consistently performing a role as "cultural vectors" in the spreading of virulent pathogens within hospitals, as well as out into the general population. As previously noted, physicians have tended to be blind to the implications of the high incidence of nosocomial infections viewed in organismic as opposed to mechanistic terms. The evidence that follows details the dramatic emergence of more and more virulent pathogens and the explosion in cases of adverse drug reactions (ADRs) related in part to clinical efforts to combat the emergence of new and deadly pathogens.
Since 1997, reports have appeared in epidemiological journals about the renewed virulence of pathogens, evident in hospitals as well as in the general community. The usual assumption in these reports has been that increases in pathogen virulence have resulted solely from an unrestricted and even careless use of antibiotics, leading to a growth in resistance to these drugs on the part of the bacterial pathogens and other parasites. Paul Ewald, a professor in the Department of Biology at Amherst College, has been warning the field of medicine that it must abandon these traditional views on the issue of pathogen virulence and recognize that increased virulence is occurring because physicians and others who attend to patients have become what Ewald has termed "cultural vectors," performing the function of "a swarm of mosquitoes" in transmitting pathogens from an immobilized patient to mobile and susceptible hosts. Ewald concludes that the pathogen infecting an immobilized patient is not in a "survival of the fittest" mode because survival for it would be impossible if the infection kills off the host. Under these circumstances, pathogens adapt their virulence to suit the situation. However, if physicians and other hospital staff function as vectors for the pathogen to move beyond its present home, not only does survival without the immobile host become possible but an avenue for unlimited propagation of the pathogen in mobile, susceptible hosts is also opened up.
A harsh and unfortunate reality to be faced is that the mechanistic mind-set of most physicians works against the likelihood of their arriving either easily or soon at a thorough understanding of the evolution of pathogen virulence that is clearly continuing to occur. Viewed from the perspective of evolutionary biology, the emergence of more and more virulent antibiotic-resistant strains of the pathogen Staphylococcus aureus, which is the most common source of nosocomial infection, is not being effectively addressed by conventional medicine for the reason that an improvement in physician understanding of the evolution of virulence has proven difficult, if not impossible, to achieve.
Ewald published a paper during the 1980’s entitled: "Evolutionary Biology and the Treatment of Signs and Symptoms of Infectious Disease." In this paper, he posed an interesting dilemma for our physicians and for the society, anticipating by more than two decades the early twenty-first century situation in which some pathogens have increased their virulence beyond the capacities of current antibiotic weapons to kill those pathogens. Numerous instances have occurred in which the most powerful antibiotics available to control Staphylococcus aureus have failed to stop this most common cause of hospital-acquired infection worldwide, in thousands of cases resulting in the death of the infected patient. The population is now threatened by the "nasty bug" known as MRSA.
Although the medical guild has been clueless on this score, Paul Ewald clearly saw this coming and did his best to forewarn the medical profession. Lacking an evolutionary mind-set, however, conventional physicians have not responded to such warnings. Quite to the contrary, as we have now seen, they have often willingly and willfully performed as volunteer vectors, functioning as the key enablers for the most dangerous of pathogens to evolve to more and more virulent stages. Ewald’s writings provide examples of the connection between pathogen virulence, host exploitation, and consequent pathogen propagation. Not recognizing the reality or the significance of these connections, physicians continue to act in ways that steadily increase the harmfulness of these pathogens. The principles of Hippocrates have been confounded once again. As we have seen, for more than two million patients each year, physician ignorance about the evolutionary processes that increase pathogen virulence yields anything but bliss. For at least ninety-eight thousand of these patients each year, this ignorance on the part of their doctors amounts to a death sentence for them.
Two decades ago, biologist Paul Ewald commented as follows about the frightening implications of this incapability on the part of medical science:
"Virulence is positively associated with... attendant-borne transmission. ...Harmful, often antibiotic-resistant, hospital-acquired pathogens can readily emerge beyond a hospital’s boundary when patients are moved, or attendants move between hospitals; the documentation is particularly strong for dangerous variants of E.coli. ...When large-scale community-wide epidemics of pathogenic E.coli have occurred, for example, transmission in hospitals was strongly implicated. ...The long-term consequences of emergence of nosocomial strains for the outside community, however, still need to be assessed. The possibility that nosocomial pathogens may tend to be not only more resistant to antibiotics, but also more inherently virulent lends some urgency to this need."
As one of the most mobile and engaged players in the universe of hospital attendants, physicians ought to be extremely aware of and concerned about the implications of a rapid evolution of pathogen virulence. Yet we know from the professional literature about failures in adherence to aseptic procedure that, despite continuous reminders to physicians, not more than forty percent of them currently comply with their own established protocols for proper hand washing in the inpatient setting. An even smaller percentage of doctors keep their stethoscopes clean. Instead of paying close and consistent attention to aseptic procedures, the challenge and complexity of the current situation is simply being ignored by physicians. Ewald has commented on the difficulty for physicians in deciding what to do in order to prevent or control increasing pathogen virulence:
Decisions [about treatment with antibiotics] that are reached will have to be reevaluated as pathogens develop greater resistance to antibiotics, and higher doses of antibiotics are required. ...In cases [when] treatment of the manifestation [e.g., treatment of a fever with an antibiotic] would be harming to the patient but helping to control spread of the disease the difficult decision for treatment would have to weigh the expected harm to the patient from [such] treatment against the expected benefits to others that might otherwise contract the disease.
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