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Friday, January 07, 2005

 

Blame the nurses – it is easy and so convenient

I have been unsettled by the superbug (of which MRSA – methicillin-resistant Staphylococcus aureus – is one) comment and coverage that seems to be the standard in the UK media. The average article, whether written by Claire Rayner or the Medical Correspondent of the Daily Mail, points the finger of blame at dirty hospitals and lazy, too-well-educated, above-their station nurses. These articles represent a blinkered, possibly ignorant, possibly misleading understanding of the phenomenon of antibiotic resistant superbugs, one that all-too-conveniently places the burden of blame on low-paid, hard-worked and politically impotent public servants.

Of course, hygiene in hospitals is important is restricting the spread of infections. However, action to provide cleaner hospital environments ought to be more about bringing cleaning workers into NHS employment, rather than contracting out to companies which offer low-pay and no security. Efficient? In the short term. But you cannot, and ought not, demand loyalty and hard work from people for who the whole character of your relationship with them is that of a continual squeeze on their standard of living. If management hold to some small, simple-minded definition of efficiency – maximising the work/pay ratio – as their guiding principle, then any sensible worker will adopt the same philosophy, and push the ratio in their favour. That is the only real ‘work ethic’ in an unashamedly capitalist environment.

But this is not the thrust of my argument against the standard coverage of superbug cases. No, rather it is the concept communicated by many of these articles, that dirty hospitals cause superbugs, which is patent nonsense. Dirty hospitals may be a source of infection, but the superbug aspect of the story, the part of the story that captures the public imagination, and fears, is not a result of hospital uncleanliness. Finding MRSA in a hospital is not a measure of its cleanliness, but stories that intimate this are a measure of the news source’s ignorance or agenda to mislead.

In fact, and unclean hospital would produce an evolutionary environment with a set of pressures contrary to the evolution of superbugs – a group of bacteria bound by their resistance to commonly-used antibiotics. No, the antibiotic resistance is the result of unrestrained and inappropriate use of antibiotics, and that alone. It is not the fault of nurses, nor is it the fault of poorly paid cleaners. Dirty hospitals, by themselves, might create an environment for infection. Infection which, in most cases, could be managed by modern health care, were it not for…

Were it not for; firstly, and most obviously, the overprescription of antibiotics to treat trivial bacterial infections – and sometimes, entirely inappropriately, non-bacterial illnesses – by doctors; and secondly, much less well known, the routine use of massive doses of antibiotics in cattle farming in the developed world. According to the Centre for Science in the Public Interest, about half of the antibiotics produced in the US are destined for use in cattle. In fact, the actual amount, though startling, is of less concern than the manner of prescription. Cattle are fed antibiotics for prolonged periods of time, effectively turning them into bio-incubators or antibiotic resistant bacteria.

The first cause of antibiotic resistance is understandable and forgivable, particularly in ‘health care as a consumer commodity’ regimes such as the US, where patient/customer pressure for prescription is a driver towards antibiotic overuse, but also in ‘health care as a public right’ regimes. The pressure on doctors to treat the individuals in their surgeries is a pressure that clouds their view of the bigger picture, and rightly so. As a result, the response to overprescription must be led from the top, with regulation rather than guidelines. In this, nationalised health care is able to institute the measures required to maintain the effectiveness of antibiotics far easier than a dispersed, privatised system. The former only requires a management edict. The latter requires legislation, a procedure that would be difficult to implement given the political clout of pharmaceutical manufacturers. Economically speaking, antibiotic resistance is a blessing to the industry, as it periodically produces new markets for patent protected, and therefore highly profitable, drugs. In the long term, and perhaps not so long term, as the number of targets for antibiotics is exhausted, this will be a disastrous strategy for humanity, sending us tumbling back to a health care situation equivalent to that of the 19th century. The surgical procedures developed over the past century will be relegated to memories of a golden age, outside, perhaps, super-sterile hospitals for the super-rich.

Our response to this dystopian, dysterile, septic future should begin with eliminating the second, absurd cause of antibiotic resistance. Unfortunately, while the EU might regulate the use of antibiotics in European cattle farming, this problem cannot be contained within a country, a continent, or a trading bloc. The global cattle market, including the heavy antibiotic users in the US industry, must be bound, internally by regulation, or externally by trade pressure, to a restriction in antibiotic use outside of the immediate and necessary causes of human health. Further, of course, we could enact a ban on the currently fashionable antibacterial products we are encouraged to routine in routine household and personal hygiene.

Of course, opinion pieces acknowledging that the real cause of both MRSA and other superbugs, resulting in what can be sensibly described as a serious, but avoidable, threat to modern standards of health care, is not a bunch of lazy nurses and underpaid cleaners, but the reckless pursuit of profit on the part of pharmaceutical (and other) companies, are opinion pieces that demand the public identify a more powerful, and less acceptably identified, enemy to human welfare, the structure of profit production.

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