Author Archives: jamesmarroquin.com

I wonder how my younger son’s autism has affected the kind of dad I am. Playing with any young child can sometimes be taxing work, but one with autism presents unique challenges.  He or she might pay little, if any attention to your efforts to engage, leaving you feeling like you’re giving and receiving nothing in return.  Trying to speak to the child can seem like just talking to yourself—akin to what some people experience when they pray.  After a demanding day at work, trying to connect with him and enter his world can feel more like a chore than a privilege.  But lately something has changed.  My time at night with him is now often the most precious part of my day.

We have a trampoline in our back yard.  In the past, when we jumped together I focused on furthering his development, coaxing him to repeat words I said or make eye contact.  But one day I decided to let my teaching goals go and just be fully present with him.  After a little while I noticed him glance up at me with a bright smile.  He could sense I was having fun instead of straining to make him better.  When he fell down, I would too, tickling him and rubbing his back.  I could feel a loving bond develop.  On and on we jumped.  The back of his hair wet with sweat, my mind free from the stresses of the day.  Now when we arrive home, he grabs my hand and walks me to the back door and to the trampoline for our nightly jumping ritual.

I hope and pray that my son will talk someday.  I will do everything I can to enable him to have that crucial capacity.  But I cannot imagine that words could make us any more close and connected than we are jumping together on the trampoline. 

The always interesting Eric Topol recently conducted an enlightening interview (linked here) with Dr. Paul Offit.  Offit is head of the Infectious Diseases Division at the Children’s Hospital of Philadelphia and author of the new book Do You Believe in Magic?  The book discusses the subject of supplements, vitamins, and alternative/complementary medicine.  

He credits Linus Pauling with giving birth to the idea that megavitamins — large quantities of vitamins greatly in excess of the recommended daily allowance — have a vast array of beneficial activities.  Pauling’s take on this matter had credibility because

he was a brilliant man. He is the only person ever to win 2 unshared Nobel prizes. In many ways he launched the fields of molecular biology and evolutionary biology. He received a Nobel Prize in chemistry as a very young man because he was able to formulate these secondary structures for proteins. He was amazing.

Nonetheless, Offit presents evidence that Pauling’s brilliance did not extend to his opinions on the health benefits of megavitamins.  He postulates that after a breathtaking career, 

something happened to (Pauling) in his mid-60s. Maybe it was just the sin of hubris because he had been so right for so long, where he believed that his notions about megavitamins were correct even when study after study showed that they weren’t correct.

Indeed, as Offit states in his interview, recent studies show that excessive doses of certain vitamins, such as A and E, can be harmful. 

Another problem with the vitamin and supplement industry is its limited regulation by the FDA.  For this reason, consumers sometimes cannot have confidence about what they are taking.  For instance, Topol notes that 

a number of years ago in The Lancet, there was a very nice randomized trial of glucosamine for knee osteoarthritis. But the problem, of course, is that the preparation that was used in the trial — the one positive trial — you would have a hard time finding that particular preparation and dose because, as you say, it is an unregulated industry.

Offit believes that 

people have this sort of false notion that there is big pharma on one side and then on this other side, there are just a group of people who want to make natural products, and that they are being made by elves and old hippies on mountainsides.  

In reality, the vitamin and supplement and field is a 34 billion a year industry, so that 

there are a lot of people making a lot of money, including big pharmaceutical companies. Pfizer bought Alacer recently, which is probably the biggest maker of megavitamins in the United States. Hoffmann-La Roche has been a player in the megavitamin and supplement game since the 1930s.

Offit also comments on the credibility celebrities like Jenny McCarthy and Suzanne Somers carry with the public despite their absence of scientific or medical training.  Since we know these figures from television and the movies, many people feel they can trust what these famous folks say.  

I have not yet read the book, but it seems that Offit is open to the idea that valuable contributions can come from the areas of alternative and complementary medicine.  He just wants to see a rigorous, scientific approach applied so that we can know what really helps people.

Here are a couple of interesting articles I’ve read over the past few days:

In Aeon, Michael Hanlon explores the mystery of consciousness.  He begins by pondering a bird he sees on a chimney of a nearby house.  

What is it like to be that bird? Why look this way and that? Why be proud? How can a few ounces of protein, fat, bone and feathers be so sure of itself, as opposed to just being, which is what most matter does?

Old questions, but good ones. Rocks are not proud, stars are not nervous. Look further than my bird and you see a universe of rocks and gas, ice and vacuum. A multiverse, perhaps, of bewildering possibility. From the spatially average vantage point in our little cosmos you would barely, with human eyes alone, be able to see anything at all; perhaps only the grey smudge of a distant galaxy in a void of black ink. Most of what is is hardly there, let alone proud, strutting, cock-of-the-chimney-top on an unseasonably cold Cornish evening.

We live in an odd place and an odd time, amid things that know that they exist and that can reflect upon that, even in the dimmest, most birdlike way. And this needs more explaining than we are at present willing to give it. The question of how the brain produces the feeling of subjective experience, the so-called ‘hard problem’, is a conundrum so intractable that one scientist I know refuses even to discuss it at the dinner table. 

Here’s another wonderful passage.

Asked to name the most violent events in nature, you might point to cosmological cataclysms such as the supernova or gamma-ray burster. And yet, these spectacles are just heaps of stuff doing stuff-like things. They do not matter, any more than a boulder rolling down a hill matters — until it hits someone.

Compare a supernova to, say, the mind of a woman about to give birth, or a father who has just lost his child, or a captured spy undergoing torture. These are subjective experiences that are off the scale in terms of importance. ‘Yes, yes,’ you might say, ‘but that sort of thing only matters from the human point of view.’ To which I reply: in a universe without witness, what other point of view can there be? The world was simply immaterial until someone came along to perceive it. And morality is both literally and figuratively senseless without consciousness: until we have a perceiving mind, there is no suffering to relieve, no happiness to maximise.

Ben McGrath’s New Yorker article on The NFL and the Concussion Crisis has changed the way I watch football this fall.  I remember being fascinated by the 1985 Chicago Bears–The Fridge, Jim McMahon and his headbands, Kangaroo Velcro Shoes, the Superbowl Shuffle–it was all so much fun.  I later played high school and a couple years of small college football, dedicating countless hours to trying to become a better player.  All of this makes taking in at least part of the biggest college and NFL games a pleasurable diversion.  

But reading about the frequency and severity of brain injuries suffered by NFL players, I feel disgusted, rather than thrilled when I see a violent hit.  McGrath’s article describes Chronic traumatic encephalopathy (CTE), a condition that is believed to result from accumulation of subconcussions experienced during a football player’s career.   CTE was 

first diagnosed, in 2002, in the brain of the Pittsburgh Steelers Hall of Fame center Mike Webster, who died of a heart attack after living out of his truck for a time. It was next diagnosed in one of Webster’s old teammates on the Steelers’ offensive line, Terry Long, who killed himself by drinking antifreeze. Long overlapped, at the end of his career, with Justin Strzelczyk, who was also found to have C.T.E. after he crashed, fatally, into a tanker truck, while driving the wrong way down the New York Thruway.

McGrath notes that

Credit for the public’s increased awareness of these issues must go to the New York Times, and to its reporter Alan Schwarz, whom Dr. Joseph Maroon, the Steelers’ neurosurgeon and a longtime medical adviser to the league, calls “the Socratic gadfly in this whole mix.” Schwarz was a career baseball writer, with a heavy interest in statistics, when, in December of 2006, he got a call from a friend of a friend named Chris Nowinski, a Harvard football player turned pro wrestler turned concussion activist. Andre Waters, the former Philadelphia Eagles safety, had just committed suicide, and Nowinski was in possession of his mottled brain. The earliest cases of C.T.E. had been medical news, not national news. Nowinski’s journalist contacts, as he recalls, were in “pro-wrestling media, not legitimate media.” He needed help.

Schwarz, acting more as a middleman than as a journalist pitching a hot story, set up a meeting between Nowinski and the Times’ sports editor, Tom Jolly, for whom Schwarz had been writing Sunday columns about statistical analysis on a freelance basis. Rather than assign the story to one of his staffers, Jolly suggested that Schwarz write it. The result, “Expert Ties Ex-Player’s Suicide to Brain Damage from Football,” wound up on the front page, on January 18, 2007. It described Waters’s forty-four-year-old brain tissue as resembling that of an eighty-five-year-old man with Alzheimer’s, and cited the work and opinions of several doctors whose research into the cumulative effect of head trauma was distinctly at odds with that of the N.F.L.’s own Mild and Traumatic Brain Injury committee (M.T.B.I.), which had been created by Tagliabue. “Don’t send them back out on these fields,” Waters’s niece told Schwarz, referring to young would-be football players.

 

Ted Johnson, a recently retired New England Patriots linebacker, read the Waters piece and called Schwarz. He was thirty-four- years old and had been locking himself in his apartment with the blinds drawn for days at a time. He believed that his problems had started in 2002, when, he said, his coach, the sainted Bill Belichick, ignored a trainer’s recommendation that Johnson practice without contact while recovering from a concussion. Schwarz accompanied Johnson to a meeting with his neurologist, Dr. Robert Cantu, who said, “Ted already shows the mild cognitive impairment that is characteristic of early Alzheimer’s disease.” Two weeks after the Waters piece, Schwarz landed another freelance submission on A1: “Dark Days Follow Hard-Hitting Career in N.F.L.”

 

Schwarz’s phone kept ringing. Several of the callers were the mothers and wives of football’s damaged men. They represented a readership far less likely to have come across, say, the annual men’s-magazine features about mangled knees, wayward fingers, and back braces, which had hardened almost into a sportswriting trope. In March, Schwarz published another front-pager: “Wives United by Husbands’ Post-N.F.L. Trauma.” Glenn Kramon, an assistant managing editor at the Times who oversees long-term, Pulitzer-worthy projects, read this piece and decided to intervene. Schwarz was given a full-time position, with no responsibilities other than to broaden his new beat’s focus beyond the N.F.L. to the more than four million amateur athletes who play organized football. Although Schwarz was assigned to the sports desk, the Times framed the story as a matter of public health, akin to tobacco, asbestos, and automobile safety. Schwarz covered high schools, helmets, workmen’s comp, coaching, and so on, earning the nickname Alan Brockovich among friends. “You can imagine how many lawyers I hear from,” he once told me.

Schwarz’s math background came in handy, too, as he batted away the statistical objections about the unknown incidence of C.T.E. from skeptical doctors. And Schwarz had the backing of a news organization that did not see itself as having any symbiotic ties to the game’s economic engine. (ESPN, which drives the national conversation on sports, invests more than a billion dollars a year in football broadcasting.) 

 

What we now know, from reading Schwarz, is that retired N.F.L. players are five to nineteen times as likely as the general population to have received a dementia-related diagnosis; that the helmet-manufacturing industry is overseen by a volunteer consortium funded largely by helmet manufacturers; and that Lou Gehrig may not actually have had the disease that bears his name but suffered from concussion-related trauma instead. (Since 1960, fourteen N.F.L. players have had a diagnosis of amyotrophic lateral sclerosis, which is about twelve more than you would expect from a random population sample.) In the manner of Elisabeth Kübler-Ross, Dr. Maroon has delineated four stages in the N.F.L.’s reaction to the reality of brain damage: active resistance and passive resistance, shifting to passive acceptance and, finally, in the past few months, active acceptance. 

I don’t envision my two young sons as ever having much aptitude for or interest in football.  But if they ever do, knowing what I know now, I will do my best to talk them out of it.

I’m honored to be involved in the formation of the new medical school in Austin.  Taking part in this exciting effort has lead me to reflect on the strengths and weaknesses of my own medical school, residency, and fellowship training experiences.  A new article in the Wall Street Journal by Dr. Jonathan David provides some interesting ideas about how medical education in the U.S. could be improved. 

 He writes

The U.S. medical education system is the finest in the world, yet it is very expensive and inefficient. Although each medical school prides itself on the quality and delivery of its curriculum, all medical schools teach basically the same material.

For the first two “preclinical” years, students immerse themselves in the study of normal and then abnormal human bodily structure and function: anatomy, histology, physiology, pathophysiology and related disciplines. The curriculum is largely standardized by national accrediting bodies, and also by common sense (no school could eliminate the study of anatomy), although many schools will add such “extras” as “creative writing in medicine” or “medical drawing.”

Historically, each school has operated in isolation from others nearby, viewing their “brands” as valuable intellectual property to be guarded. For this reason, each of the 170 or so U.S. medical schools invests a huge amount of time and money to develop and implement its course of study. But students generally skip the live lectures to watch videos of those lectures and read the books on their own.

The uncomfortable truth is that medical schools today provide a preclinical education that their students neither want nor need. Students hate live classroom lectures, especially for basic content, and they know they learn better on their own time at their own pace. Yet schools still rely on these educational relics.

A more individualized system of self-study using the latest in digital technology, along with small study groups to integrate knowledge, would provide more effective learning. It seems wasteful to pay 170 anatomy professors to design 170 separate courses and then bill students for this privilege.

I recommend reading the entire piece.  It strikes me that a challenge common to nearly all reform efforts is preserving the wisdom of tradition, while being open to new, unfamiliar ways of doing things. 

There is a lot of talk these days about changing our health care system from “pay for volume” to “pay for value.”  The idea is that we currently reimbursement doctors and hospitals according to the number of services delivered rather than how well they make us.  This perverse system of incentives results in runaway health care spending that doesn’t necessarily result in a more healthy citizenry.

There is certainly truth in this way of thinking.  But to my mind, it drastically oversimplifies the situation.  To illustrate why I believe this to be the case, I present a letter entitled Performance Indicators and Clinical Excellence from the October 5-11th 2013 issue of The Lancet.  The author Chris Kenyon writes:

Attending post-intake ward rounds in various National Health Service (NHS) trusts around the UK, I am concerned that clinical expertise is being crowded out by a need to meet various key performance indicators.

In one hospital, I was told on arrival that the trust had, over a year, moved from the bottom to the top category of performing trusts. I was therefore puzzled when soon thereafter I attended a consultant post-intake ward round where a patient seen had ascending leg weakness mistakenly diagnosed by the admitting doctor as Guillain-Barré syndrome. The consultant spent little time reviewing the history of the patient (missing the history of pseudo-seizures), did not test the patient’s reflexes or power in the legs, and concluded that the patient required intravenous immune globulin. The consultant did, however, introduce all members of the ward round to the patient, check that any drug allergies were filled out on both pages of the drug chart and a checklist of 23 other items, which were ticked off or not according to the consultant’s compliance thereof. A sticker containing the 25 items ticked off was duly placed in the notes, the patient received intravenous immune globulin for their somatisation disorder and the patient contact scored 100% for audit purposes.

On post-intake ward rounds in the past, the consultants would, with a few pertinent questions and clinical findings, recognise the most likely diagnosis. This would determine a streamlined approach to the further investigations and management. Performance indicators are necessary, but with the limited time available for each consultant-patient contact, I wonder how much thought has been put into how the setting of performance targets such as this list of 25 items has crowded out the time available for clinical excellence.

 

I close with words from a sign that hung in Albert Einstein’s office at Princeton.  “Not everything that counts can be counted, and not everything that can be counted counts.” 

Urinary Tract Infections (UTIs) are among the most common problems I see in my practice.  Since they are usually easy to treat, UTIs are sometimes a welcomed break from the more complicated, time-consuming issues I encounter.  Nonetheless, complications from UTIs (such as kidney infections and sepsis) result in more than 1 million hospital admissions annually in the U.S.  Cranberry juice blocks bacteria from adhering to the urinary tract.  So for decades cranberry products have been used to prevent UTIs.

An article in the most recent issue of the Journal of the American Medical Association (JAMA) analyzed 13 studies testing whether cranberry products really do decrease the incidence of UTIs.  The study concluded that “overall, cranberry products were not associated with lower rates of symptomatic UTIs.”  The study’s authors acknowledge that they cannot definitively conclude that cranberry products don’t prevent UTIs, only that there is not robust scientific evidence to support their use for this purpose.  The article hypothesizes that perhaps not enough of the active ingredient (proanthocyanidin) in cranberries was consumed to be able to prevent UTIs.  It states that “in theory, a patient would need to consume 224 to 280 grams of cranberry juice twice a day indefinitely to achieve any potential benefit” in preventing UTIs. 

If somebody with recurrent UTIs is interested in trying cranberry juice to address the problem, I see no harmful effect from doing so except for the increased sugar and calorie intake. 

So what does work to prevent UTIs?  A couple of common sense solutions are staying hydrated and urinating immediately after sex.   For women suffering from frequent UTIs, using a topical estrogen cream and/or taking a regular low dose antibiotic for prevention have both been shown to be effective.

Practicing primary care medicine resembles the off-and-on activity of the game of baseball.  The routine of annual check ups and minor problems can suddenly be interrupted by the discovery of urgent, life-threatening conditions like pneumonia, pulmonary emboli, and coronary artery disease.  As internist Danielle Ofri writes, “In contrast to specialists who have their diseases cut out for them—cardiologists get patients with heart problems, pulmonologists get patients with lung problems—the general practitioner has the far more challenging task of sifting out serious illness from the vast sea of aches and pains that afflict the human race.  And this is what we fear, that one of these hundreds of patients will indeed harbor some grave illness and that we will miss it.”

But preventing, detecting, and treating serious health conditions are not the only tasks that matter.  It’s also worthwhile and satisfying to effectively address the minor annoyances that afflict people.  Accordingly, I thought I’d share some pearls an esteemed dermatology colleague shared with me yesterday about brittle fingernails.  This occurs when superficial grooves in the nails lead them to split.  To treat this problem he recommends an over the counter Biotin 3 mg pill daily, applying moisturizer to the nails regularly, and avoiding excessive water exposure to the nails.  If this is not effective, there is also a new, expensive product called Nuvail that can be applied to fingernails to prevent friction on the nail surface and protect against the effects of moisture.

Nearly everyday in my practice I see the tragic, avoidable results of smoking:  A woman with emphysema that requires her to be constantly connected to an oxygen tank, a man with a cancer in his throat that has robbed him of the ability to eat or speak, fatal and debilitating heart attacks and strokes that occur at much too young of an age.  The list goes on and on.  Indeed, nearly 450,000 Americans each year die of complications of smoking.  Anything that can help avoid this great amount of human suffering deserves our consideration.

Accordingly, I offer the following reflections on electronic cigarettes.  First of all, what are they?  As a Medscape article explains:

“Electronic cigarettes — e-cigs — look like cigarettes in size and shape, but they are nonflammable, so you don’t smoke them. Instead, you “vape” them.”

While nicotine is the substance that causes pleasure and addiction to cigarettes, it is not what causes the manifold maladies that result from smoking tobacco.  Rather, it is the other noxious, toxic chemicals in tobacco that harm and kill.  So, do e-cigs have any of these toxic chemicals?  A new study in the journal Tobacco Control analyzed vapors from a dozen e-cig brands and also found some toxic substances.  But these toxins were found at levels 9 to 450 times lower than in regular cigarette smoke. 

While e-cigs don’t appear to expose people to the same high level of toxins that real cigarettes do, they effectively reproduce the nicotine rush produced by inhaling smoke from burning tobacco.  Thus, they have the potential to be a much less harmful way for people addicted to nicotine to continue to get their fix.  Thus, for my patients who are not interested in smoking cessation, I recommend they change to e-cigs as a less toxic option.

Nonetheless, I share some of the concerns voiced by others about e-cigs.  Since using e-cigs might seem to be a safe practice, they may promote nicotine addiction and possibly be a pathway to smoking tobacco.  People who otherwise might have quit smoking altogether may now transition to long-term e-cig use, thus inhaling the low levels of toxins the Tobacco Control study revealed.  Finally, there is the concern that e-cigs are used by some smokers, not to quit their habit, but as a way to smoke (or vape) in public places where smoking tobacco is banned. 

In sum, however, it appears to me that e-cigarettes offer a much less harmful alternative for tobacco smokers who are unwilling or unable to end their addiction.

A recent analysis of 10 studies showed that taking cinnamon supplements improved fasting blood glucose in people with diabetes.  Here is a link to an article commenting on the study. I find that people appreciate incorporating these natural remedies into their treatment for chronic diseases.  Another natural strategy I recommend to my patients is  increasing their cherry intake to decrease their frequency of gout attacks.  Here is an article reporting on the study that supports this treatment.  

The Centers for Disease Control and Prevention (CDC) recently released a “landmark” report on the rising and lethal threat of antibiotic resistance. CDC director Tom Frieden sounded the warning that “if we are not careful, we will soon be in a post-antibiotic era.”  By this he means that infections we now routinely treat may someday not respond to antibiotics.  In the following review of the book Superbug, I touch upon many of the issues addressed in the CDC report.

With its ominous title and front-cover description (“Medicine disregarded it … Antibiotics can’t control it …”), Maryn McKenna’s Superbug is packaged as a bio-thriller. In this literary subgenre, encompassing both fiction (The Andromeda Strain) and nonfiction (The Hot Zone, as well as the book under review), the security and predictability of modern civilization are suddenly shattered by the outbreak of an enigmatic infectious disease. We see the terrible truth that our way of life is fragile and tenuous, subject to wild, dark forces. The stories’ heroes—usually doctors and scientists—strive to make sense of the plague and turn back the tide of entropy. At the end of these tales, when order has been restored, we feel a rush from our brush with danger and relief that the chaos has been calmed. But instead of providing the consolation of a happy ending, Superbug warns that the worst is yet to come.

The book’s subject, a bacterium named staphylococcus (staph) aureus, has probably been with humans as long as we have existed. While it often lives innocuously on our skin, staph can cause infections when it enters our bodies through means such as a cut or inhalation. The release of the first antibiotic, penicillin, in 1944, inaugurated an era of effective treatment for previously fatal bacterial maladies such as staph. With the 20th century witnessing its second world war, this miracle cure buoyed the beleaguered myth of progress. A May 1944 cover of Time featured a portrait of penicillin’s discoverer, Sir Alexander Fleming, and declared “His penicillin will save more lives than war can spend.”

But soon after penicillin came into use, strains of staph resistant to the antibiotic began to appear. A June 16, 1953 article in the New York Times entitled “Antibiotic Effect Feared on Decline” reflected scientists’ growing concern. In 1960, after years of intensive research, a promising new antibiotic named methicillin was introduced in the United States. Pharmaceutical chemists had specially designed it to foil staph’s mechanism for resisting penicillin. The creators of this breakthrough germ-killer were confident that if resistance to it were to occur at all, it would be far in the future. So it came as a rotten surprise when a 1961 issue of the British Medical Journal reported three cases of staph infections unresponsive to methicillin. Thereafter, all strains of staph resistant to methicillin and its antibiotic descendants were termed methicillin-resistant staph aureus (MRSA).

Superbug describes how in the decades since its first appearance, MRSA has become a worsening problem in hospitals around the world. Catheters and surgical incisions provide the bacterium with ports of entry. Once inside the frail, sick bodies of hospitalized patients, MRSA grows with little resistance. Gathering ill individuals together, hospitals act as Petri dishes, with workers often unwittingly spreading the bug from patient to patient. For instance, a 1980 MRSA outbreak in a Seattle hospital that killed 17 patients and sickened many more was ultimately traced to one nurse who was colonized with the bacterium in her ears, nose, armpits, and groin.

The menace of hospital-acquired MRSA is part of a larger, important story in American medicine that has largely been ignored in the ongoing health care debate. In 1999, the Institute of Medicine’s landmark study To Err is Human concluded that from 44,000 to 98,000 people die each year as a result of preventable medical errors—the equivalent of a 747 plane crashing every other day. The transmission of infections such MRSA to hospitalized patients was cited as one of the chief causes of this avertable loss of life.

Superbug reports that in 1990s, a new strain of MRSA appeared. The pathogen had hitherto been exclusively a hospital phenomenon. But just over a decade ago, an emerging version of MRSA began attacking previously healthy people who had not been recently hospitalized. The book tells the tragic tales of individuals with innocent-appearing respiratory or skin infections who overnight became deathly ill from what was later discovered to be MRSA. In one awful story, a young couple in the Hyde Park area of Chicago took their 17-month-old son to the emergency room (ER) because of a fever. Shortly after they arrived home from the ER with some antibiotics and reassurance that the boy would be well, his lips became blue and his breathing labored. By the time they returned to the hospital, their toddler’s lungs had been destroyed by pneumonia and he shortly thereafter died of septic shock. What at first appeared to be a simple infection that would respond to first-line antibiotics turned out to be MRSA.

As the MRSA problem worsens (by 2005 causing more annual deaths than AIDS), researchers have identified potential factors contributing to its growth. Superbug shows how some of the sources of the MRSA surge flow from cultural, political, and economic forces. Physicians’ injudicious prescription of antibiotics for viral infections is driven by the demand for an instant germ-killing cure, when all that is really possible and necessary is some rest and cough medicine. As more Americans enter prison or jail, the overcrowding, suboptimal health care, and poor sanitation often present in these institutions have made them perfect MRSA incubators. Indeed, epidemiologists have calculated that correctional facilities are more potent than hospitals at disseminating the infection into the surrounding community. Finally, there is the effect of industrial livestock production. In the 1950s, cows, chickens, and hogs crowded into feedlots and barns began to routinely be fed small doses of antibiotics as research showed this caused them to grow faster. This liberal use of antibiotics propagates drug-resistant bacteria that the closely confined animals pass to and fro in much the same way that inhabitants of prisons and hospitals do. New strains of MRSA and other antibiotic-resistant pathogens are thus created and spread into the human population by means such as flies, wind, and people.

While effectively addressing the issues fueling MRSA’s rise will be difficult, having antibiotics available to treat the infection could pose just as a great of a challenge. Superbug reports that MRSA may be developing resistance against the few antibiotics still able to kill it and pharmaceutical companies are not in a rush to generate new ones. This is because antibiotics are only used for days to weeks, making them less revenue-generating than medicines that treat chronic conditions such as diabetes or hypertension. Moreover, after spending hundreds of millions of dollars developing an antibiotic that works against MRSA, pharmaceutical companies face the very real prospect that an unpredictable mutation will render the new antibiotic ineffective after only a few years.

While the fearful future that Superbug presents is not cause for fleeing to the nearest sterile bubble, the suffering and expense that MRSA causes are real and deserve a wise, robust response. At the same time, despite the triumphal predictions of some futurists, human mastery of nature will never be complete. So even if we are clever and lucky enough to find a silver bullet for MRSA, it will not be long before another superbug emerges in its place, putting human ingenuity and resourcefulness again to the test.