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World Health Organisation

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Antibiotic Apocalyse

I have never advocated that people who routinely feed low doses of antibiotics to livestock should be executed without trial. That would be too harsh, too irrevocable. There should be fair trials, and fines for a first offence, and prison for a second. Only habitual offenders should face the death penalty.

But first, there has to be a law. At the moment, it isn’t even illegal in most countries.

At the United Nations last week, every single member country signed a declaration that recognises the rise in antibiotic resistance as a threat to the entire enterprise of modern medicine. It’s a start, but that’s all it is – and time is running out.

“The emergence of bacterial resistance is outpacing the world’s capacity for antibiotic discovery,” World Health Organisation director-general Margaret Chan warned the meeting. “With few replacement products in the pipeline, the world is heading toward a post-antibiotic era in which common infections will once again kill.”

The declaration urges countries to cut back on the use of existing antibiotics in order to preserve their effectiveness, to make better use of vaccines instead, and to spend more money on developing new antibiotics. It doesn’t put any actual money on the table, however, and it doesn’t even make make it illegal to pump “sub-therapeutic” doses of antibiotics into
farm animals. (It can’t. National governments have to do that.)

I was not really recommending the death penalty for feeding antibiotics to livestock. That was just for dramatic effect. But the reckless misuse of antibiotics is rapidly destroying their effectiveness.

A recent study by Public Health England found that the proportion of campylobacter bacteria that are resistant to ciproflaxin, the standard antibiotic in cases of food poisoning, has risen from 30 percent to 48 percent in just the past ten years. If we don’t stop the rot we are heading back to the 19th century in terms of our ability to control infections. Even minor wounds and simple operations will carry the risk of death.

The same goes for communicable diseases. In the 19th century tuberculosis was the biggest killer of young and middle-aged adults in Europe and America. With the discovery of streptomycin in 1944, isoniazid in 1952, and rifamptin in the 1970s it ceased to be a major health problem. But now the drug resistance has grown so great that at least 190,000 people worldwide died of tuberculosis last year.

The problem of bacterial resistance has been understood for a long time. If the antibiotic kills all the harmful bacteria it targets in the person or animal it is given to, then no resistance develops. But if it only kills off the weaker ones because it was a very low dosage, or because the course of drugs was not finished, then the surviving bacteria will be the most resistant ones.

They will pass their resistance on to all their descendants, who will undergo similar episodes of winnowing out the the less resistant ones many more times, and gradually the resistance grows. The only way to keep antibiotics effective, therefore, is to use them as rarely as possible, and to make sure that they kill off all the target bacteria when they are used.

We are not doing this. Doctors over-prescribe antibiotics, often giving them to people who do not have bacterial infections just to get them out of their offices (and sometimes getting a kickback from drug companies for each prescription they write). And nobody makes sure that patients complete the course of treatment even though they already feel better.

Much worse is the widespread practice of giving regular low doses of antibiotics to cattle, pigs and chickens, partly as a means of controlling the spread of disease in their cramped and insanitary living conditions, but mostly because it makes them put weight on more quickly. Getting them to the slaughterhouse a week or two faster is money in the hand.

This insanely greedy and reckless practice is now banned in the European Union, but it is still commonplace in China and the United States. In fact, 80 percent of American antibiotic production goes to farm animals who are not ill, and as intensive farming methods spread to developing countries so does antibiotic use in agriculture.

This has to stop. So does over-prescribing by doctors in developed countries, and the over-the-counter sale of antibiotics without prescriptions that is so normal in many developing countries. “We are now staring at overwhelming evidence of rampant antibiotic resistance, across all ages, all over the country,” said Dr Vinod Paul, head of pediatrics at the All-India Institute of Medical Sciences in Delhi.

We also need a whole new generation of antibiotics to replace those that are hopelessly compromised, which requires persuading large pharaceutical companies to change their research priorities. (They make more money by developing new drugs that address the chronic health problems of the affluent, so we’ll have to subsidise them.)

It all has to be done, and it has to start now. “On current trends,” said Dr. Chan at the UN, “a common disease like gonorrhea may become untreatable. Doctors facing patients will have to say, ‘I’m sorry, there’s nothing I can do for you’.”
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To shorten to 725 words, omit paragraphs 6 and 7. (“A recent…year”)

Chernobyl: The Numbers Game

20 April 2006

 Chernobyl: The Numbers Game

 By Gwynne Dyer

April 26 is the 20th anniversary of the explosion and fire in the Chernobyl-4 nuclear reactor, so the long-running dispute over how many people actually died as a result of the accident is back. And now the growing public argument in Western countries about ending the de facto ban on new nuclear power stations has lent wings to the debate.

Last Tuesday the World Health Organisation published a report estimating that 405 people died in the first decade after the accident, almost all of them former plant workers, firefighters and soldiers who were exposed to massive radiation doses in the initial explosion or during the nine-day struggle to put out the fire in the reactor core. But over 200,000 people were involved in some aspect of the clean-up operation, and some of them as well as some people living near the site will also develop cancers from their lesser exposure to radiation sooner or later.

The WHO’s best estimate is that about 9,300 people will eventually die from Chernobyl-related cancers. Greenpeace International, on the other hand, has just issued a report predicting that the number of cancer deaths directly attributable to Chernobyl will ultimately reach 93,000.

This is as much an argument about the future as the past, since the outcome of the revived debate in the West about the desirability of nuclear power depends heavily on the public’s perception of the risks involved. It’s not how the debate SHOULD be settled, but both sides know that it’s how it will be.

The West effectively abandoned building new nuclear power stations after the accident at the Three-Mile Island reactor in the US in 1979 (which killed nobody) and the Chernobyl accident in 1986 (which killed quite a lot of people). Few existing plants were shut down, and in a few countries, notably France and Japan, nuclear energy continues to supply most of the nation’s electricity, but the global population of big nuclear power reactors has fluctuated in a narrow band between 400 and 450 for the past twenty years.

Now there is a new wave of reactor-building in Asian countries where rapidly growing economies have created a huge demand for electricity, and few voices have been raised against it in those countries. Even in the West, the debate has been re-opened as concern about global warming has grown. Apart from hydro-power, which is only available in certain areas, nuclear energy is the only available short-term option for producing very large amounts of base load electricity without adding to the greenhouse gases that cause the warming.

The real arguments for and against nuclear power are about complicated technical and financial issues. Would the same amount of investment in “renewables” like wind power produce as much electricity, and how do you allow for the fact that the wind does not always blow? Would investing in techniques like “sequestering” the carbon-dioxide output from conventional coal, oil and gas-fired power-plants (capturing it and pumping it into underground reservoirs) be a better way to spend the money — and how soon could such technologies be available on a large-scale?

Those are the real issues, but everybody involved in the argument knows that “safety” will be what decides the outcome in the public debate. Since Chernobyl is the only accident involving a nuclear power plant in the past fifty years that has killed any members of the public, just how many died has become a bitterly contested question. Unfortunately, it is also a hugely misleading one.

There is no doubt that thirty people died in the immediate struggle to contain the accident, twenty-eight of them from massive radiation overdoses. Of the 139 people who were treated for acute radiation sickness, another nineteen died. But after that, all the other deaths attributed to Chernobyl are statistical inferences. That doesn’t mean they did not occur, but it does mean that the range of plausible conclusions, given the state of the medical and demographic data in the affected area (Ukraine, Belarus and western Russia), is very wide indeed.

Moreover, predictions about the “final death toll” are almost meaningless, because everybody dies eventually, and about 30 percent of people in developed societies die of cancer. Whether it’s ultimately 9,300 or 93,000 people who die as a delayed effect of the Chernobyl accident, they will mostly die from cancers that develop late in their lives, only a few months earlier than they were statistically likely to anyway.

The massive hydrogen-bomb tests in 1962, which released about a hundred times as much radiation as Chernobyl into the atmosphere, had a similar effect. Worldwide, the average radiation dose from those tests was ten milliSieverts, roughly the same as most people living within a few hundred kilometres (miles) from Chernobyl received in 1986. Ten milliSieverts of radiation is calculated to shorten a person’s lifespan, on average, by four days — but averages lie. What those tests really meant was an early death for an unlucky few, and nothing for everybody else.

In the case of nuclear power, the number of lives that might be at risk from accidents is certainly only a tiny fraction of those that are at risk from global warming, but that’s not how the argument will be pursued in public. The debate will be mostly about the alleged dangers of nuclear power, not about whether it is really the best way to produce huge amounts of power without also producing huge amount of carbon dioxide.

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To shorten to 725 words, omit paragraphs 5 and 6. “The West…the warming”

The Coming Pandemic

1 June 2005

The Coming Pandemic

By Gwynne Dyer

The long-term solution is to invest many billions of dollars and a huge amount of political capital in persuading peasant families throughout China and South-East Asia to change the way they raise their poultry. The urgent short-term task is to develop a way of mass-producing influenza vaccine far faster than is now possible. It’s urgent because “the world is in the gravest possible danger of a global pandemic,” as Dr Shigeru Omi, Western Pacific regional director of the World Health Organisation, told an emergency conference on avian flu held in Vietnam two months ago.

The H5N1 avian flu virus first crossed into human beings in 1997, but it has clearly been mutating in recent years in ways that make it more capable of moving from birds to people. The spate of human infections in mid 2003 in China and South-East Asia was so serious that over 100 million domestic birds were killed or died in those countries before it subsided in early 2004, but there was only a few months’ respite before bird-to-human transmission began again last June.

The virus has now appeared in wild birds who can carry the virus far beyond its original reservoir in domestic chickens in southern China and South-East Asia: in late May China closed all its nature parks after 178 migratory geese were found dead from the virus in Qinghai province in the north-west. The most recent outbreak has so far killed 53 people in Vietnam, Thailand and Cambodia — and even more ominously, the first probable case of human-to-human transmission was recorded last September in Vietnam.

The danger of a global flu pandemic that could be as bad as or worse than the “Spanish influenza’outbreak of 1918-19 (which killed 40 to 50 million people, half of them young, healthy adults) comes from the fact that a strain of influenza virus that normally affects only birds can swap genes with a strain that is highly infectious between human beings. If people with the human type of influenza should also be infected with the avian type (through direct contact with infected poultry), the gene swap can easily occur — and direct human-to-human transmission becomes possible. At that point, given current patterns of international travel, the world might be only weeks away from a global pandemic.

We don’t know if avian flu viruses swapping genes with human types caused the lethal Spanish influenza, but that was certainly the source of the much milder “Asian flu” outbreak in 1957-58 (which killed 70,000 people in the United States alone) and the “Hong Kong flu” pandemic in 1968-69 (50,000 US deaths). Given the rate at which influenza viruses mutate, we are overdue for another pandemic — and this one could be a monster.

The H5N1 virus is resistant to most anti-viral drugs, and in the avian form it has been getting steadily stronger. Early outbreaks killed around 10 percent of poultry flocks; more recent ones have been killing up to 90 percent.

In people who have caught avian flu, the death rate has been horrendous: 50 to 75 percent of those infected. A gene-swapped version that is directly communicable between human beings might be less lethal, but it could still far exceed the 1-2 percent fatality rate of the Spanish influenza. To make matters worse, this version of avian flu has a long incubation period. Unlike the SARS virus that killed 774 people two years ago, it may be very hard to stop before it spreads into the general population.

“When people were transmitting the (SARS) virus they were already showing signs, so it could be picked up at airports with temperature (detectors),” explained World Health Organisation spokesman Peter Cordingley. “With (avian) flu you can be infectious before you show any signs.” If human-to-human infections start to spread, there could be not only huge loss of life, but global economic chaos as air travel is shut down to contain the spread, borders are closed, and essential services break down because too many of their workers are off sick or just hiding from the flu at home.

Governments are already arming themselves to deal with this pandemic — on 1 April President George W. Bush added “influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic” to the list of diseases for which a quarantine can be declared — but there is no vaccine. As things stand now, none could be available for months after the pandemic begins. That is why five teams of scientists, writing in last week’s edition of the journal “Nature”, urged a permanent global task force to react quickly to outbreaks of bird flu. If it is not done, they warned, millions will die.

The first opportunity to create such a task force will be at the G-8 summit in Scotland next month, and its first priority must be to develop new and easily produced vaccines to deal with the expected outbreak. But lasting progress, as Dr Samuel Jutzi of the UN’s Food and Agriculture Organisation said at the Vietnam meeting in March, depends on “addressing the transmission of the virus where it occurs, in poultry, specifically free-range chickens and wetland-dwelling ducks.” In other words, a couple of hundred million Asian peasants have to be persuaded to stop living in the same space as their poultry. A tall order, but a necessary one.

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