Why Did the Chicken Cross the Road? To Get Antibiotics : A Review of Big Chicken

Snip20181124_3.png

One of the most pressing aspect of the antibiotic resistance crisis is the role of antibiotics in agriculture and the link with human infections. This is an aspect of the problem that has received mixed treatment in the past. It was clear that agricultural use of antibiotics was a problem but its impact on human infections was debated, not well known, and not conclusive though all doctors probably could recite the statistic that 80% of antibiotics sold in the US were for used in animals. Many people, myself included, focused heavily on the superbugs stalking our hospitals and ICU and thought almost exclusively about infection control and human antibiotic stewardship.

However, with the publication of Big Chicken: The Incredible Story of How Antibiotics Created Modern Agriculture and Changed the Way the World Eats, I suspect things will change. This book written by, in my opinion, the premier science journalist, Maryn McKenna, is something extraordinary. I read books in this genre continually and I can saw that McKenna’s ability to tell a compelling non-fiction story while weaving together history, politics, science, and medicine in a manner that teaches and leaves the reader completely captivated is unrivalled.

Big Chicken, which published in 2017, is much more than a book on unraveling antibiotic use in chickens, who are fed “routine doses of antibiotics on almost every day of their lives.” It is nothing short than a history of the chicken industry in the US — which breeds “for everything but flavor: for abundance, for consistency, for speed” — and it is only by understanding antibiotic use in that context that one can really grasp the issue. This is the book’s chief value.

The book teems with so much good information that it is impossible to capture in a short blog post. Some highlights include:

  • How antibiotics facilitated the transformation of grain into muscle making an “active backyard bird into a fast-growing, slow-moving, docile block of protein”. Slaughter weights of chickens have doubled in the past 70 years and can be achieved in half the time due largely to the use of growth promoting antibiotics, which allowed chickens to become more than just egg-layers to most farmers.

  • The story of the McNugget

  • The use of antibiotic-laced harpoons to shoot whales!

  • The questionable role of a Mississippi Democrat congressman

  • The change in culture that sparked companies like Chick-fil-A and Perdue to revaluate antibiotic use

The book also has great anecdotes of disease outbreak investigations — one featuring a young Mike Osterholm — and scientific studies that increasingly linked antibiotic use in animals to huma infections. The book also discusses how policy evolved with respect to this issue.

For anyone interested in a great story that traces the roots of a major scientific/medical problem, I highly recommend this book. For those who work in infectious disease, it is required reading (as are all of Maryn McKenna’s books).

Antibiotic Resistant Infections Kill More than Car Accidents: A Review of Superbugs

Snip20180701_5.png

I often say that the biggest infectious disease problem humans face is that of antimicrobial resistance. I am not alone in this assessment and today there are myriad books describing  this problem and its many facets. However, a recent book I read on this topic, Superbugs: An Arms Race Against Bacteria, provides a unique lens to view the problem: economics. Below I give a short overview of the prime value I took from this book.

Superbugs is a book that stems from a high level review of antimicrobial resistance commissioned by then UK prime minister David Cameron and is written, not by scientific subject matter experts, but by economists and policymakers (Jim O'Neill, William Hall, and Anthony McDonell).

I think it is not difficult for anyone to see that a drug-resistant infection will be, on average, more expensive to treat than a drug-sensitive one. This cost disparity exists for several reasons that include the expense of switching therapy to a an appropriate regimen, the expense of isolation of patients with drug resistant infections, and the increased severity of illness because time to appropriate antibiotic therapy is delayed. 

The book is divided into two parts that focus, respectively, on the problem and solutions to drug resistance. To me, the chief value of the book is the authors attempt to quantify the problem of antimicrobial resistance because as they note a whole different audience -- beyond the health one -- is more receptive to a quantitative analysis. Several of their estimates are worth noting.

  • 1.5 million people die of antimicrobial resistant infections annually (more than die i automobile accidents)
  • Total worldwide costs (direct and lost productivity) are approximately $864 billio

The book provides a comprehensive overview of the economic challenges inherent with antibiotics: namely, stewardship programs that diminish revenue from new antibiotics, low prices of antibiotics vs. other pharmaceuticals, and the ability to substitute antibiotics.

One of the most valuable portions of the book, to me, is their discussion of diagnostic tests. Much of inappropriate antibiotic prescribing is done for viral infections. It is thus obvious that by employing diagnostic tests to determine whether a patient's symptoms are caused by a virus or a bacteria and which virus it might be could curtail injudicious antibiotic prescribing (and provide valuable epidemiological information) however they are seldom employed despite their availability. Superbugs delves into the dilemma that has stifled the routine use of diagnostics for infectious disease contrasting it the use of advanced diagnostics tests that are standard of care for cancer. 

Chief amongst these obstacles, as they note and I have experienced first hand, is the hospital siloing of costs. Because a multiplex point-of-care molecular diagnostic test deployed during an office visit for bronchitis is more than the entire cost of the visit plus the inappropriate antibiotic prescription that will likely result, testing is foregone. But economics is not only about the seen, but also the unseen, and taking a wider perspective allows one to realize that the costs of antimicrobial resistance driven by the inappropriate prescribing outweighs the cost of running a diagnostic test. 

The book concludes with policy recommendations to solve what the authors believe to be a tractable problem that are informed by a thorough analysis of the problem that are familiar to those that follow this issue and include increasing awareness, increased R&D, and the inclusion of all relevant parties (including agriculture). 

I recommend Superbugs to those who would like an up-to-date holistic analysis of a pressing public-- and individual -- health threat.