The Post Antibiotic Era? Why Antimicrobial Stewardship is Critical for the Future of Infectious Disease Prevention .

 

When-Life-Gives-You-Mold-Make-Penicillin_1899-lSome clinical epidemiologists (myself included) have suggested that a general disregard exists in surveillance and monitoring when it comes to medical and health practitioner staff concerning follow-up with patients diagnosed with an infectious antigen, and moreover, the handling of disinfection of infected surfaces and garments. While there is a sense of protection due to the availability of vaccines and antibiotics, there is an illusion that health staff and practitioners have the requisite knowledge to ensure patient adherence to prescribed treatments, the necessary follow-up is often insufficient to prevent reinfection.

Penicillin: The wonder drug. After returning from a vacation Alexander Fleming was cleaning up his running experiments including some petri dishes containing staphylococcus bacteria. He noticed something odd on one dish; it had sprouted a small colony of mold. He also noticed that they bacteria were avoiding the area around the mold. Fleming later identified the mold as a real strain of Penicillin Notatum, and it seemed as though the mold was preventing the bacteria from growing. Further experimentation by Fleming found that penicillin was capable of killing a number of harmful bacteria known that time, however it would be a number of years before penicillin could be refined and used as a treatment. Nevertheless, what would become the first wonder drug had been discovered purely by accident. Over the following 25 years, penicillin would become highly effective at treating a number of bacterial infections. However, its effectiveness today is drastically being reduced, as are many antibiotics.

Bacteria become resistant through overuse and misuse. When prescribed an antibiotic for a cold, influenza, sore throat, bronchitis, many sinus infections or any other viral infection, the antibiotic does nothing to treat the illness but instead destroys helpful bacteria in the body. Another overuse of antibiotics is in the livestock meat industry. Livestock producers give antibiotics to farm animals to make them grow faster, help them survive crowded stressful and unsanitary conditions. It has been estimated that 70% to 85% of all antibiotic use is in livestock meat industry. You maybe asking yourself, how does overuse or misuse lead to antibiotic resistance? If an antibiotic effective, doesn’t it remain effective? Bacteria are living things, and as such follow much the same processes as higher organisms including mutation and evolution.

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Conjugation: bacteria can acquire antibiotic resistance genes from other bacteria in several ways. By undergoing a simple mating process called “conjugation,” bacteria can transfer genetic material, including genes encoding resistance to antibiotics (found on plasmids and transposons) from one bacterium to another.

Bacterial conjugation is the transfer of genetic material between bacterial cells by direct cell-to-cell contact or by a bridge-like connection between two cells. It is a mechanism of horizontal gene transfer, as are transformation and transduction (although these two other mechanisms do not involve cell-to-cell contact). During conjugation, the donor cell provides genetic material (plasmid or transposon), and most conjugative plasmids have systems ensuring that the recipient cell does not already contain a similar element (eliminating duplication and ensuring enhancement). These enhancements may include antibiotic resistance, xenobiotic tolerance, or the ability to metabolize small molecules for energy, thus the foundation of a newer, more resilient bacterium.

AR-CDC 2017Evolution: the same natural forces that have produced every species on the planet benefit a bacterium. The term survival of the fittest is even more evocative of bacteria, as their “life-cycles” are short, and are measured in hours. Bacteria don’t have a life span, and a bacterial age is the period up to cell division, which can be from a few minuets to several hours (or many years on inanimate surfaces such as rock), and is unlimited by the mode or reproduction (asexual). Just as a microorganism evolves very slightly with each new generation, often taking hundreds of thousands of years (think of the Galapagos Finches), and because bacteria reproduce so quickly, they evolve at a significantly faster rate than longer-lived organisms. In any population, whether we are talking about finches or bacterium, there are many genes present within the population that express in a variety of ways, and the traits of these genes our mixed.

Like the finches discovered by Charles Darwin in the Galapagos Islands, the original decedents found themselves in a new, challenging environment, and were forced to adapt to the environment (this is referred to as a selective pressure), and evolved to survive in their new surroundings. Over thousands of years, new varieties emerged from the original population to take advantage of the environment. If we speed this up thousands of times, we can see how bacteria react in much he same way to environmental pressures.

Adaptation: while we certainly would not suggest that bacteria think, they certainly have developed adaptations. When this bacterium is exposed to a toxin (anti-bacterial), the vast majority is killed. But a very small number, through a fluke of genetic recombination from the many genes present allows them to survive. These few are now able to reproduce, and when they divide, their descendants naturally inherit the same resistance. Over time, due to the rapid lifecycles of bacteria, a new resistant strain evolves. Researchers are finding that when stressed by repeated cycles of antibiotic treatment, some bacteria can evolve and adapt for more quickly then imagined, in some cases within a few days, and seem to be able to suspend their “G time” (a period of little or no growth) to help it survive antibiotics. This is really bad news for patients who have compromised immune systems which are susceptible to opportunistic infections through immune dysfunction or immune suppressant therapies.

When a bacterium becomes resistant to the antimicrobial treatments that have historically been used, it becomes significantly harder to treat. These resistant forms of bacteria fall into a set of Hazard categories depending on factors including the seriousness of infection and difficulty in treatment.

Urgent Concern includes Clostridium difficile (C-Diff), Carbapenem-resistant Enterobacteriaceae (CRE) and Neisseria Gonorrhea (resistant to cephalosporin).

Serious Concern includes Multi-drug Resistant Aceinetobacter, Drug Resistant Campylobacter, Multi-drug Resistant Pseudomonas Aerugionosa, Drug-resistant Shigella, Vancomycin-resistant Enterococcus (VRE), Methicillin-resistant Staphylococcus Aureus (MRSA), Drug- resistant Streptococcus Pneumonia, at least one form of Drug-resistant Tuberculosis, and two forms of Drug-resistant Salmonella.

Growing concern includes Vancomycin-resistant Staphylococcus Aureus, Erythromycin-resistant Group A Strep, and Clindamycin-resistant Group B Strep.

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What can you do to protect your family?

Think like an epidemiologist: start with hand washing; this is your best defense against infections that cause diarrheal and respiratory illnesses. Regular hand washing after certain activities is the best ways to remove viruses and bacteria and avoid spreading them to others.

Stay Up-to-Date with Vaccines: Prevention is key to staying healthy. It is always easier and better to prevent disease than to try to treat it. Vaccines are responsible for the control of many infectious diseases that were once common, including polio, measles, diphtheria, pertussis, rubella, mumps, and tetanus. Since their introduction, vaccines have prevented countless cases of infectious diseases and saved millions of lives.

Prevent the Spread of Food borne Infections: keeping your water safe and clean will help you from preventing waterborne illnesses from occurring, including bacteria (and a few nasty parasites).

Never take an antibiotic for an infection like a cold or flu and never try to pressure your healthcare provider into prescribing an antibiotic.

Do not save antibiotics and never take antibiotics prescribed for someone else.

 

In the end, each of us must be responsible for our preventative health, and overuse of antibiotics in prescribing and food animals will continue to threaten public health. But there are some steps we can take to avoid these infections. Antimicrobial stewardship has become a significant aspect of public health, and each of us must do our part.

Neurogenesis and The Neurology of Grief and Loss

 

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Give sorrow words: the grief that does not speak whispers the o’er-fraught heart and bids it break. ~Shakespeare

Since beginning my study of cognitive-behavioral psychology decades ago, the idea of what constitutes acceptable topics of exploration have changed drastically. What was once limited to the reflective/passive responses and active listening promoted by cognitive therapist like Carl Rogers has given way to a more scientific approach to the emotional state of the human mind.

The last several years have witnessed significant insight into the understanding of what exactly happens in the brain when we are in emotional states. Utilizing functional MRIs and CAT scans, researchers can see firsthand how states like joy, sorrow, and grief affect our neurology. With surprising insights. While it has been a long suspected that practices like mindfulness and meditation can greatly alter our psychology and even cause physical changes to the brain, we now know that the more unwelcome mental states also have neurological equivalents. One area that is getting renewed attention is grief. Most therapists will agree that unmitigated grief often leads to depression, and left untreated, depression can greatly diminish a person’s life, both experientially and chronologically. The first question to ask, therefore, how does grief affect our physical brain?

This is not the easiest question to answer, as every person is unique just as each of our brains is slightly different. That being said, anyone we know who has lost a friend, relative, or pet can describe the feelings of loss and loneliness, of sadness and a feeling of emptiness. While these very in intensity from person to person, our shared experience of loss allows us to empathize and to understand how the other person is feeling. Now we have an insight into how their neurology is attempting to cope.

Just as the body goes into shock after a physical trauma, so does the human psyche go into shock after the impact of a major loss. ~ Anne Grant

Psychologist and author Richard Lazarus developed a scale to help understand the stress that most people feel when dealing with loss on a scale of 0-100. The death of a spouse is not surprisingly at the top of this list, but perhaps not for the reason, we might think. The death of a spouse is also the death of a dream. As cognitive beings, we live at once in the past, the present, in the future. A life partner is someone who shares a large part of that cognitive schema. People who speak of the loss of a spouse they say that a part of them has been ripped away, or, they may feel as if they are incomplete. The person who was so critical to their being is no longer there. Divorce also rates high on this scale, 73, according to Lazarus, as the loss of the dream is not quite as total as in death.

Other significant stressors include imprisonment (63), the death of a close family member or friend (63), personal injury or illness (50), Being fired from a job (47) and surprisingly, retirement (45). Marriage comes in at 50, and marital reconciliation earns a score of 45. According to Lazarus, anyone who has a total of 300 after these stressors are added up is put at a significantly elevated risk of illness. Those between 150 and 299 have a moderate risk and those under 150 only a slight risk. While Lazarus’ stress scale may cover many life altering events, it is certainly not complete, nor does it take into account other factors. Among them the death of a beloved pet, which can rate as high as 50, which may not be surprising, especially to those who have a beloved dog or cat.

It is expected that when a close relative or friend passes, the grieving process can be a lonely one, and everyone seems to grieve differently. Each of us mourns the loss of the individual relationship, and no two relationships are identical. Because of this it is impossible for anyone on the outside being able to formulate an accurate assessment of the person’s grief. Even though there may be others who are sharing in that loss, for example, siblings may share in the loss of a parent, nevertheless, each relationship is unique, and every loss is grieved differently.

Regardless of the loss, the stress that accompanies the grieving process is very real. This stress can become a burden to both the physiology and psychology; both of which are negatively impacted by the system designed to handle stress, namely the hypothalamus-pituitary-adrenal axis, or HPA. If you are a regular reader of my blog you have read a number of times about how our HPA axis system helps us survive threat or danger, but if left switched on can begin to cause significant damage, both to our bodies as well as our minds.

Lazarus’ stress scale is important because it does two things: it allows us to quantify stress from life events, and it points to how stress negatively impacts our health by weakening our immune response. A number of studies have shown that survivor groups, and grief support drastically increases overall health, lengthens life, and greatly improves the quality of life. This support in the grieving process support both psychologies (cognitive and behavioral aspects), but also greatly decreases stress, and its effect on the HPA axis and the resulting negative impact on the inflammatory process and immune response. Drs. Janice Kiecolt-Glaser, a psychologist, and Ronald Glaser, an immunologist, found that high-stress relationships impeded healing of injury; inflammatory response proteins can be released by intrapersonal stress and conflict resulting in a negative impact to our immune response system. These researchers also found that the inflammatory response worsened depression. At the same time, being in the presence of the familiar can greatly decrease these depressive symptoms through the release of oxytocin, one of the neurotransmitters often referred to as the “feel good” chemicals (If you want to learn more about these, the book pictured below is an exceptional guide).

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Regardless, grief seems to be a very natural and necessary adjustment to loss. If this grief is downplayed or ignored, the results can be depression, anxiety, or maybe manifest in physical symptoms. We all work through grief differently, but we all must work through it. And whatever our loss, refusing to acknowledge it and allowing the sadness to become clinical depression is hardly beneficial.

The stress hormones, particularly cortisol, which are beneficial in the short term, are destructive in the long term. If we become too depressed for too long, the neurology of our brain can be permanently affected. But how?

Much research over the past few years has begun to focus on the process of neurogenesis. Neuroscience has discovered that the adult brain can indeed continue the process of neurogenesis, and one area of significant interest is the hippocampus.

The hippocampus is crucial for learning and in the creation of memories, according to researcher Jessica Malberg, and works in orchestra with other parts of the brain, for example, the amygdala, to govern emotion, mood, and in the association of emotion to memories. Other researchers are discovering that some activities will increase the rate of neurogenesis in the hippocampus. They have also concluded that depression inhibits this neurogenesis by flooding the brain (and body) with stress chemicals. It has long been known that depression is unhealthy to our psychological well-being, and now we know it is unhealthy to our physiological health as well.

During periods of grief, we need to recognize that neurogenesis is incompatible with depression, and should be avoided for several reasons, one of which is that depression just does not feel very good, either physically or mentally. The headaches, the feeling as if we were punched in the stomach, these are often the result of a depressed and stressed state. What do we do when we are trapped in this grief? The seemingly natural ability of our minds to put us into a deep depression is very real, and it may seem as if there is no way to avoid the downward spiral. Yet researchers and therapists explain that the cure for this depressed mental state is may be as simple as exercise.

Reducing the effects of stress chemicals can be done through stimulating the feel-good neurochemicals like dopamine, serotonin, and oxytocin. This can be achieved through physical exercise. In fact, researchers at the Salk Institute found that sustained physical exercise promoted neurogenesis in the hippocampus, the region of the brain critical for the formation and regulation of emotions (and memories linked to emotions), as well as controlling many autonomic functions like digestion and heartbeat. What’s more, the researchers found that neurogenesis in the hippocampus improves the creation of new memories.

In his brilliant 2006 bookMaking Happy People: The Nature of Happiness and Its Origins in Childhood,” biologist Paul Martin suggests that even a brief ten-minute walk can greatly elevate mood, at least for a few hours. Of course, a daily walk of 10 minutes or more will over even a short time, start to change positively effect our mood, and increase our ability to deal with stress. It has long been known that physical exercise is effective in relieving depression and anxiety. Along with exercise, shared experiences and companionship further stimulate neurogenesis and reduce feelings of grief.

Researchers at Princeton University found that social interactions and companionship are necessary components of a healthy brain. Companionship is so critical to health brain function that researchers found among people living in isolation did not experience neurogenesis despite regular exercise. Sociologist and community psychologists tell us that humans are communal mamas, and being part of a group is necessary for health and longevity. One researcher set out to prove this.

Dr. James Coan is a professor of neuroscientist who used a functional magnetic resonance imager (fMRI) to measure has shown that we need more than just an internalized idea of social roots; we need to feel as if we belong. British neuroscientists also found similar results when using an fMRI to measure neurological responses to touch, finding heightened activity n the somatosensory cortex (the hub for all sensory experiences). These finding further support the idea that personal, physical and emotional experiences of others are critical to our neurology and our psyche. We are social creatures to be sure; do we benefit from the touch of our fellow humans only? As it appears, the answer is no.

In a 2013 study of Fibromyalgia patients, those spending time with a therapy dog showed significant decreases in pain and depressed mood. Another study examined the presence of animals and found significant increases in positive social responses from children with neurological disorders, seeming to suggest that the emotional and psychological benefits of socializing extend to pets as well. And it is not just therapy animals that can have positive effects on humans, with measurable results.

Living with a pet lowers blood pressure and decreases the response to stress, and thereby boosts our immune systems. People who live with pets also seem to have a higher survival rate following a heart attack. Some researchers found the nurturing connection between humans and their pets have significant positive implications for health care, reducing costs and improving longevity, and the use of therapy animals in children’s cancer treatment improved the moods of the children.

In the end, sharing our lives with another person, or a cherished pet, helps us avoid feelings of loneliness that so often leads to depression; allows us an external focus for our attention, love, and compassion, the science seems pretty sound. Sharing our lives with others helps us worry less, have less anxiety, less depression, and as the studies discussed here, experience much less pain. Pets, much like other humans, not only make us happier, they can help make us healthier. This is why the death of a friend, or the death of a cherished pet, can often leave us sad, depressed, and devastated.

The reality is that you will grieve forever. You will not ‘get over’ the loss of a loved one; you will learn to live with it. You will heal and you will rebuild yourself around the loss you have suffered. You will be whole again but you will never be the same. Nor should you be the same nor would you want to. ~ Elisabeth Kubler-Ross

Autism: Can Computational Biology and Environmental Health Finally Provide Answers?

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The Increasing Rate of Autism in America

When I first studied psychology as an undergraduate student, the rate of autism in the United States was one in 10,000. Today it is about one in 55. And while some suspected that the rise in autism was due to changes in diagnostic standards, new findings point to the increases in environmental toxins for the increase in autism. This was a significant finding, as many in the medical and psychology fields had been watching the increasing numbers of autism diagnosis with more than a little concern. While the exact cause or causes of autism are still not known, significant progress is being made to understand how the environment, particularly toxins, have significant impact on fetal neurodevelopment

Computational Biology

Even those familiar with biology and biochemistry may not be well versed in computational biology. This is because computational biology is less retrospective, and more prospective in nature. Computational biology looks at the application of data analysis and theoretical modeling to understand biology, behavior, and complex social systems, in order to better understand and prediction the interplay among the psychological, the physiological, and the social. Beyond this, computational biology also involves the use of computer modeling, applied mathematics, biostatistics, biochemistry, molecular biology, genetics, ecology, neuroscience, anatomy, and physiology. This bringing together of such diverse specialities allows researchers to create a more complete picture of diseases and conditions in hopes of better understanding cause, prevention, and treatment.

Epidemiology

If you are a regular reader of my medical blog, you know that epidemiology is the study of how diseases or conditions impact a larger population, and Clinical Epidemiology has many similarities to computational biology, particularly in regards to predictive modeling and ascertaining direct and indirect impacts to the community. When combined with Environmental Health Science, this approach can bring new insight into how our health is impacted, how healthcare can be altered to include the ecological aspects, and how diagnosis can be modified to include impacts from the environment. One such insight is a novel way of looking at destructive neurodevelopment impacts associated with the environment.

Each year, over 300,000 newborns die within the first month of life due to complications from congenital anomalies according to the World Health Organization. Many who survive are faced with long-term disabilities that significantly impact their families, causing significant disruption in healthcare systems and the society. The World Health Organization suggest that, although some congenital abnormalities are the result of genetics, infections, or poor maternal nutrition, environmental toxins play a significant part.

Recent Studies

In a study from the University of Chicago, researchers found that autism and intellectual disability rates were positively associated to harmful environmental factors during congenital development. The researchers found significant correlations between the rate of congenital malformations of male genitalia, the rate of autism, and exposure to environmental toxins, particularly those comprised of micro molecules (those molecules small enough to pass through the placental barrier). These included some plastics, some prescription drugs, pesticides, and other manufactured chemicals, commonly referred to a teratogens (meaning an agent that causes malformation of an embryo), a word that first appeared in the medical literature about 1951. In essence, the introduction of these micro molecules or teratogens alters or damage fetal development during vulnerable periods.

The University of Chicago researchers gathered data from over a third of the population of the United States, finding that fetuses, particularly males, were highly sensitive to toxins in the environment, including lead, petrochemical prescription medications, pesticides, mercury, and a host of other man-made synthetics. This is not the first time researcher suspected a link between autism and the environment. In 2009, The University of California Davis department of public health sciences reviewed 17 years of state data that tracked developmental disabilities, finding the increase in autism rates corresponded with the increase of environmental toxins.

Another study published in the New England Journal of Medicine compared brain autopsies of autistic children who had died from unrelated causes to those of normal brains. The brains of autistic children revealed abnormal patches of disorganized neurons that disrupted the usual distinct layers that make up the brain’s cortex. Research suggests that these abnormalities occurred in utero during critical developmental stages (between 18 and 31 weeks).

Life in a Disposable Society

As a disposable society, we have not always been concerned about where our trash went, provided it went somewhere out of sight. As a child, I recall going to the “Dump” with my father and watching people burning trash, tires, anything that could be burned. As a result, all of that trash, burned or otherwise, the refuse of the past 75 years or so has become part of our environment, and as a result, our ecology contains some chemicals that impact the neural development of all animals that come into contact with them. They include Mercury, lead, bromide, pesticides, and herbicides.

A Toxic Soup

Today we include the built environment in human ecology, and the list of toxins has increased significantly. While the rates of autism have remained steady in Europe, where Genetically Modified Organisms (GMO’s) are banned, along with the pesticides used with them. In fact, the rates of neurodevelopment disorders seem to remain stead in the Europe Union, Australia, Japan, and in total some 60 nations have outlawed or significantly reduced GMO crops, or have banned any use of GMO’s altogether. Meanwhile in the US, government agencies continue to approve the use of these chemicals at great concentrations, completely discounting their connection to health ailments. Today, a chemical outlawed in the EU and dozens of other nations, Glyphosate, (the active ingredient in herbicides) is routinely used on food crops and livestock feed.

While environmental regulators should be aware of the number of birth defects caused by Glyphosate, only those agencies in the European Union, Japan, and Australia have completely outlawed their use. Despite established research showing these chemicals cross the placental barrier injuring fetal development, they are still widly used in the US.

According to a study in Reproductive Toxicology, pesticides associated with GMO foods were found in maternal and fetal blood, and later tests revealed these same pesticides in the blood samples from other women as well, along with the presence of Bacillus thuringiensis (Bt), a bacteria toxin manufactured by several chemical makers. The people living in the United States continue to be inundated with toxic chemicals, and one study, examined 160 toxic chemicals, found that almost all women tested positive for 43 of them.

Finally, A study by the U.S. Geological Survey titled Pesticides in Mississippi Air and Rain: A Comparison Between 1995 and 2007, found Glyphosate and its byproduct AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid), a compound that mimics the effects of the neurotransmitter glutamate, was found in over 75% of the air and rain samples taken from Mississippi in 2007.

And you are worried about vaccines?

Water

ecowater.com“Cross the meadow and the stream and listen as the peaceful water brings peace upon your soul.” ~ Maximillian Degenerez

Recently I decided to get a new scale for the bathroom, and being easily impressed by technology, I selected one with several assessments aside from weight. This included measures for muscle weight, bone weight, BMI, and, interestingly enough, a percentage of bodyweight comprised of water. Mine generally runs between 49.8 and 51%, which is low, as adult males should have around 60% (55% for women).

Water, as any 8th grader will explain, is of utmost importance to living things. Depending on species, some animals owe 90% of their body weight to water. The human brain is comprised of about 70% water, and the lungs somewhere around 80%. That’s a lot of water. At 190 pounds with water comprising about 50% of my body weight, 95 pounds of me is water. At 8.34 pounds per gallon, on an average day, I contain over 11 gallons of water! No wonder I have to go to the bathroom at 2 AM! Every day.

As I calculated my water weight, I thought about another water-related issue; how many people lack access to clean water. As an epidemiologist, I am trained and educated to prevent illness or disease, and to consider the environmental as well as biological, psychological, and cultural contributors to those diseases and illnesses. Environmental factors are responsible for a majority of infectious disease, and a good deal of the chronic ones as well.

For example, we know that polluted drinking and cooking water is responsible for hundreds of thousands of deaths world-wide from diseases like cholera, and that clean drinking water goes hand-in-hand with adequate sanitation. We also know that about 85% of the world’s population lives in the driest half of the planet, and about 783 million people do not have access to clean drinkable water. Nearly 2.4 billion people, or one in three, lack access to adequate sanitation; as a result around 7 million people die every year from disasters that effect water access and water-related diseases including Trachoma, Amebic dysentery, Cholera, Giardiasis, Typhoid, Hepatitis A and E, Lassa fever, Guinea worm, and Hook worm. It might come as a surprise that a substance so fundamental to life on Earth would be so squandered, misused, and wasted.

Before you think that this is a problem limited to far-flung places like Africa or Southeast Asia, even a nation as undeniably wealthy as the United States has not always considered water cleanliness, or even water conservation, as being anything so important as commercial profit. From Texas to Tennessee, public water sources n recent years have been found to have as high as 30 times the federal limit of lead. About 4 million Americans get water from small water source suppliers who did not bother with the required tests, and did not conduct the tests properly, in direct violation of federal safe drinking water laws. These tests are necessary because without them, regulators of the water utilities do not know if the water is clean, and the people end up drinking unsafe or polluted water. A recent investigation found that over 2,000 communities the US skipped the required and mandated lead testing on more than one occasion. Hundreds of these repeatedly failed to properly test for lead for five or more years.

We should not be that surprise by these findings. Placing profit ahead of people has a long and proud tradition in America, going back to the 18th century, and this greed has had a direct impact on the health of Americans and their drinking water, then and now.

Back in 1799, Alexander Hamilton and his associates in the Bank of New York and New York Branch of the First Bank of the United States monopolized the banking industry. Several other groups had attempted to break Hamilton’s stranglehold on banking, but being so well politically connected, the Bank of New York had little trouble squeezing out competition. Much of the city was clustered together in overcrowded neighborhoods, and Manhattan was no exception. The residents of Manhattan were clustered on the southern end of the island, and the drinking water was said to have been “horrid, smelly, and filled with effluence.” The people clamored for clean, or at least cleaner drinking water. Something must be done.

Following an epidemic of yellow fever that swept the city, a group of investors calling themselves the Manhattan Company formed with the magnanimous purpose of providing clean water to lower Manhattan, to end the suffering of the people who had little or no access to clean water. Aaron Burr (Who would later duel with, and shoot, Alexander Hamilton) founded the company, and Burr’s brother-in-law, Dr. Browne, suggested the ills suffered by the residents of Manhattan were caused by polluted drinking water (on this he was correct), and that residents that were clustered around lower Manhattan could be supplied with fresh water piped in from the then pristine Bronx River.

While the city had planned on designing, building, and maintaining the water system, Burr and his associates campaigned for the privatization of the project, suggesting that a private company could do the job better and cheaper. The charter for the Manhattan Company to build and maintain the water system was granted; thanks to Burr’s influence, the charter stated that any surplus capital not used in the water system could be used for “banking transactions.”

While the original plan would cost upwards of 2 millions dollars, and would have provided a significant population with clean drinking water, it seems clear that the company’s true focus from the beginning was in becoming part of the banking industry in New York. Although the original construction plans called for clay pipe, to bring the water from the Bronx River located miles way, the company used cheap materials such as hollow logs, and piped water from dug wells and cisterns erected in nearby buildings in the congested areas of Manhattan where sewage was allowed to mix with drinking water. The Bronx River impoundment project was at first delayed, then ignored, and eventually forgotten.

“What made New York a prosperous port – its deep saltwater rivers – made its drinking water lousy. By the middle of the eighteenth century, Manhattan’s water was already infamous: there was too little of it and what little there was tasted terrible.”

~ Jill Lepore

While the Manhattan Company had originally raised over 2.2 million dollars to construct the water delivery system, only about one hundred thousand dollars would be spent on the project. The rest of the funds were used to start the Manhattan Company Bank. In 1808 the Manhattan Company sold its waterworks to the city for 1.9 million dollars and turned completely to banking. To maintain the illusion it identified as a water company as late as 1899. True to form, the Manhattan Company maintained a Water Committee which yearly attested that, true to its founding charter, no requests for water service had been denied. Considering the quality of the water, this seems to have been an accurate assessment. Within the first few years, The Manhattan Company Bank made loans to Burr and other insiders for over $60,000. Meanwhile the city’s water supplied continued to grow worse. Eventually, a real water system was designed and implemented, but before several cholera epidemics took thousands of lives.

The Bank that had started under the guise of providing clean water to citizens of Manhattan would eventually merge with Chase National Bank in 1955 to become Chase Manhattan. Then in 1996, Chase Manhattan was acquired by Chemical Bank, who retained the Chase name, to form what was then the largest bank holding company in the United States, before acquiring J.P. Morgan & Co. in 2000 to form JPMorgan Chase & Co.

Just think, it all started with the need for clean water, the promise to improve the health f the citizens, and the greed that so often seems to permeate from such things.

Today we know how critical clean drinking water is to health. Keeping the body fully hydrated is essential for heart health; when the body becomes dehydrated, the blood thickens causing resistance to blood flow. This results in elevated blood pressure. Dehydration can also lead to a rise in blood cholesterol as the body attempts to prevent water loss from the cells. When you combine high cholesterol and high blood pressure, there is a significantly elevated risk of coronary heart disease, according to the American Heart Association.

Dehydration can also lead to an increased risk of obesity, a condition that is associated with type 2 diabetes. When combined with high blood pressure and high cholesterol, a condition known as Metabolic Syndrome can occur. Dehydration can cause issues with the kidneys, infections of the bladder, and kidney stones.

But these conditions can be avoided by drinking two 8-ounce glasses of water before breakfast, lunch, and dinner, according to a recent study published in the Journal of the American Dietetic Association. Not only does proper hydration keep you healthier, it can help keep weight off for at least a year. In the end, regularly drinking adequate amounts of water speeds up our metabolism and makes us feel more “full” while promoting good physical, mental, and emotional health. That is of course, provided we have access to it, and today, even in America, millions of families do not.

Because of political corruption, corporate greed, or shortsighted practices, tens of millions of American citizens lack clean drinking water. Like Samuel Taylor Coleridge’s Ancient Mariner, many have “water, water everywhere, but not a drop to drink.”

Prisoners of Childhood

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While I try to respond to inquiries from readers, recent accounts in the press have prompted this month’s post. It should be mentioned that the development of chronic conditions and the association with child abuse was the topic of my dissertation. That work reflects in this month’s post.

Childhood should be carefree, playing in the sun; not living a nightmare in the darkness of the soul. ~Dave Pelzer, A Child Called “It”

 Virtually everyone is familiar with the term Posttraumatic Stress Disorder, or PTSD. And while PTSD has been recognized for many decades, it has been known historically by different names including Battle Fatigue, Soldier’s Heart, and Shellshock. Whatever the name, it is Psychological Trauma. While there are some agreed-upon definitions of posttraumatic stress disorder, the bottom line, at least from a physiological and neurological standpoint, PTSD results when an event or series of events have completely overwhelmed the person’s stress adaptation system.

The Stress Response System

What exactly this stress adaptation system is and how it works has only recently been discovered. In 1976, an endocrinologist named Hans Selye proposed a neurophysiological model for understanding what he termed the mind/body connection. He suggested that stress reactions were based on perception and cognition, showing that a person’s perception had a direct effect on their biological systems through a psychological stress response. Dr. Selye came to recognize this response in his patients: those who suffered from higher rates of disease, ranging from infections to cancers, reported having experienced psychological trauma.

A Product of Nature

The stress response system evolved for one purpose: surviving an attack. Often know as the fight or flight response, researchers have now added a third state, known as freeze, as some mammals tend to simply stay still to avoid a threat. The fight/flight/freeze response evolved among mammals to help them survive threats through a complex system of endocrine glands, hormones, and neurochemicals known as the Hypothalamic-Pituitary-Adrenal, or HPA system.

The HPA works through the perception of danger. Being attacked, or seeing another attacked, or perceiving oneself in mortal danger of attack or death, can stimulate the HPA system to prepare the body fight, flee, or freeze in help it to survive. The fight/flight/freeze response is governed by the HPA and prepares the body to meet the threat through the manipulation of glucocorticoids, primarily cortisol, corticotrophin-releasing hormone (CRH) and arginine-vasopressin (AVP). The HPA response causes significant changes in major organ systems as a response to the threat. Digestion slows, blood flow is reduced to the skin (to reduce blood loss by cuts, bites, scrapes) and the blood flow to the arms, legs, shoulders, brain, eyes, ears and nose increases (allowing the brain to think faster, preparing the muscles to run or fight, increasing the hearing to detect threat sounds, and dilating the pupils to focus). The body will begin to sweat to avoid overheating during fight or flight (giving off a particular ‘stress odor’ or diaphoresis, which is detectable by humans and other mammals, for example dogs). The mouth dries as saliva and gastric juice production decreases, as does blood flow to the digestive system.

The HPA system works very well to survive threats, and has worked this way for many hundreds of thousands of years. But it’s not foolproof. Sometimes the threat is not real, but the system switches on just the same. If a person (or another mammal) experiences a severe trauma, the system may not turn off at all. Because the body cannot return to its unstressed or homeostatic state, the long-term effects of the flight/fight/freeze response begin to take their toll.

Chronic Stress

Medically speaking, stress results when an organism fails to return to homeostasis. Homeostasis refers to the normal state of the organism before the threat. While our hunter-gatherer ancestors faced threats from predators on a daily basis, and most of us face nothing more threatening than a bad driver, the system that helped them survive remains largely unchanged. While occasional stress may actually be beneficial as it allows us to perform, or to push ourselves to reach goals, provided that stress is short term, the body can return to it’s normal state. For our ancestors, once the threat was dealt with, they could return to the homeostatic or pre-stressed state. Short-term stress is not damaging, however long term or chronic stress is a significant problem.

Chronic stress has deleterious consequences and harmful effects. This is due to how the system works, what it has evolved to do, and why it is a short-term adaptive process. When activated long term, even at relatively low levels, the results are often a compromised immune function, weight gain, developmental impairment, cardiovascular disease, dyslipidemia and insomnia. Chronic stress has also been associated with Metabolic Syndrome and Arteriosclerosis.

Chronic Stress and your Organ Systems

Long-term stress affects the body in several ways, and more than a few medical conditions can be traced to overstressed organ systems. Chronic stress can cause major skin problems including acne, psoriasis, eczema, and dermatitis. It can also make your skin more sensitive and more reactive to sunlight. A person suffering from chronic stress will often experience migraines or cluster headaches due to the build up of tension in the neck and shoulders. Chronic stress can cause anxiety and depression, and new evidence links stress to some forms of dementia and memory loss. Because stress increases blood pressure, there is a long-established link between long-term stress and heart disease. Prolonged stress also reeks havoc in maintaining blood sugar levels which can have direct implications in how the heart functions. Stress can also result in heart arrhythmias, and stress has long been known to cause inflammatory responses in a number of organ systems. Stressed directly affects how well our gut functions. When stressed our stomachs stop processing nutrients as effectively and decreased nutrient absorption and oxygenation can decrease by 75% in the intestines resulting in significantly reduced metabolism and decreased enzymatic output.

Immune and Metabolic Impact of Stress

During the stress response, the pancreas produces more than the required amount of insulin to allow the muscles to convert all available glucose to energy. However, when consistently elevated as in the case of chronic stress, the increased insulin begins to cause damage to arteries and other organs. The immune system is severely impacted by the stress response, and chronic stress greatly impacts the immune system’s ability to defend against foreign bodies like bacteria, viruses, or cancer cells. The elevation of corticosteroids released during stress negatively affects the immune system by impacting the number of leukocytes available in the blood, making us far more susceptible to infections. New research is currently being done which may show a link between long-term chronic stress and inflammatory diseases such as multiple sclerosis, type-1 diabetes, rheumatoid arthritis, lupus, Crohn’s kidney disease, chronic fatigue syndrome, kidney disease, ulcerative colitis fibromyalgia, and a host of other inflammatory response disorders. Chronic stress is also involved in the neurobiology of mood disorders and functional illnesses, including anxiety disorder, bipolar disorder, insomnia, posttraumatic stress disorder, borderline personality disorder, ADHD, major depressive disorder, and emotional burnout. There is also new research into the long-term effects of PTSD from child abuse.

PTSD, Child Abuse, and Chronic Stress

Memories instilled in children, particularly around physical, psychological, or sexual abuse, are often multi-schematic, meaning they are stored in different parts of the brain as emotional stimuli, visual stimuli, physical stimuli, and auditory stimuli. For this reason, a smell, a picture, anything that stimulates the sensory system may trigger the fight/flight/freeze response, and one reason why childhood memories are lasting. While physical injuries may heal over time, at least in some degree, psychological scars do not. Psychological trauma from child abuse is at epidemic levels in the United States, according to the Centers for Disease Control and Prevention (CDC). In 2012 alone, nearly 700,000 children were victims of abuse, and the National Children’s Alliance reported that abuse was suspected in an additional 3.8 million incidents involving children under the age of 18 years. Perhaps most shocking is that children between birth and one year of age suffered the highest rate of abuse. According to the CDC, the direct and indirect costs of treating child abuse in the United States are nearly $125 billion annually.

Often the results of child abuse, whether it is physical, emotional, or sexual abuse may not manifest for years. A group of researchers investigated whether or not a history of assault and childhood could be associated with chronic health conditions in later years. The team used data from a large study that involved over 6000 middle-aged Americans, finding a significant association between abuse in childhood and the diagnosis of hypertension. The team concluded that, although the abuse had taken place decades earlier, the negative impacts on psychological and physiological health remained long after the event or events. Perhaps it is not surprising that psychological disorders were also found among the same child abuse survivors including depression and anxiety. However it is hypertension that has been termed the silent killer, but the real culprit is stress. While there are often few symptoms of hypertension if accompanied by other conditions, like dyslipidemia, cardiovascular disease, and atherosclerosis, the resulting cluster of conditions called Metabolic Syndrome. In this study, several of the preconditions of Metabolic Syndrome were found to be associated with a history of posttraumatic stress in childhood at least within these study participants.

 

How Cronyism, Nepotism, and Unqualified Providers are depriving you of the best in Health Care

nepotism

Currently, there is a bill before Congress called the Access to Quality Diabetes Education Act of 2015 (HR 1726, S 1345) which is to amend title XVIII (Medicare) of the Social Security Act to recognize only state-licensed or -registered certified diabetes educators or state-licensed or -registered healthcare professionals who specialize in teaching individuals with diabetes to develop the necessary skills and knowledge to manage the individual’s diabetic condition and are certified as a diabetes educator by a recognized certifying body. However, many currently working as diabetes or nutritional educators would not qualify for this license or registration as they lack both the educational background and the experiential training.

While many see this as simply more regulation, there is another way of examining the issue. Shouldn’t someone suffering from metabolic syndrome, type- two diabetes, or a similar metabolic condition expect that the person they are seeing has a minimal education and professional background? This certainly does not seem to be too much to ask. Unless of course, the person in this position lacks the education or training, or possibly both, to work in this capacity. This seems to be an issue with many, and that is because of nepotism or cronyism which has placed an unqualified provider in the position they are neither educated nor trained to fill.

Cronyism, hiring your friends or favorite staff to fulfill positions based on your liking of them rather than education or experience, and nepotism, the hiring of family members for the same reasons create unqualified providers that deprive people of the best health care possible. But don’t just take my word for it.

Jone L. Pearce, from the Paul Meringue School of Business at the University of California at Irvine, wrote that cronyism and nepotism are bad for everyone, and provides the research to back it up. According to the author, there is substantial quantitative research on nepotism and cronyism in the workplace as well as negative impacts on overall performance.

Max Weber (1864-1920) conducted observational research of German organizations, finding bureaucracies were nepotism and cronyism were constrained by minimal requirements provided superior functioning when compared with those organizations that were based upon, and allowed, nepotism and cronyism among other favorite leveraging. But this was nearly 100 years ago, so why hasn’t business learned the lesson?

While it probably does not surprise anyone that the owner of the local market employs his teenage son, and perhaps some of his friends, as bagboys or check out clerks, it should come as a surprise when persons in positions of authority that directly impact medical treatment, medical research, or healthcare, should have obtained those positions through a combination of higher education and experience. But even in the hallowed halls of medicine, we find nepotism and cronyism. The difference is that while you probably don’t care if your canned goods are placed in the same bag, you would probably be concerned that the person in charge of some aspects of your health care was placed in that position through means other than education and training. And you should.

For those of us who pay for our health care coverage, as well as those who have earned health care through a lifetime of work, when we go to a hospital, a clinic, or medical Center, we take it for granted that the people who sit in the offices that dictate our healthcare are qualified to perform the job. But this may not be accurate.

Favoritism, whether nepotism or cronyism not only diminishes our healthcare, it also decreases the performance of those healthcare professionals who have legitimately earned, through years of education and training, positions of leadership in hospitals and medical centers. When organizations place untrained in positions based on personal relationship or other favoritism, it not only decreases the effectiveness of that office and the staff but also negatively affects employee attitudes and perceptions. The last people we want distrustful of the medical establishment are those we rely on to deliver that medicine to us.

And rest assured, those working under these leaders who gained their position through means other than education and experience do not go unnoticed by their fellows or their staff. Realizing that the person you work for lacks both education and experience, and yet has control over your unit or department, is frustrating and undermining. Often the result is that coworkers, staff, and eventually employers are more just satisfied and less committed to supporting these supervisors and directors. And although the outcomes are frequently a reduction in employee satisfaction, a reduction in patient care and patient satisfaction, and an overall decrease in the personal appraisal of the hospital or clinic, I can point to more than a few situations in my state where this is a current issue.

In the end, cronyism and nepotism place loyalty and obligation not to the hospital, clinic or medical center itself, but instead to friends or family, those who secure the position. Cronyism is damaging to healthcare delivery because it supports the placement of unqualified people in positions of decisions regarding healthcare, medical research, or patient care. Decades of research in political science, economics, and even anthropology, have demonstrated that nepotism and cronyism are bad for organizational performance, and often spell disaster for both the manager as well as the staff.

You say Potato, I say.. Sponge Cake?

medical

Since starting this blog a few years back, I have had some interesting feedback on the diagnostics and research of the odd ailments and conditions, and yet, I’ve gotten more than a few questions that really defied an easy answer. Not surprisingly, these were not health or medically related. Here is a short post that I’ve compiled based on two such questions.

Question one: “What is a Clinical Epidemiologist?”

Question two: “Do you work with bugs or skin?”

Let me try to address these questions and clear up any confusion concerning epidemiology, entomology, and dermatology.

Epidemiology

A clinical epidemiologist is a medical professional who studies diseases and the way they spread. Primarily, they use research to improve clinical and patient-oriented healthcare. Some clinical epidemiologist work in labs, or in a forensic capacity conducting investigations of disease outbreaks. Whether they work in a hospital setting, a research laboratory, or in the field, ultimately, the focus is on reducing the occurrence of negative health issues.

Some of the duties that a clinical epidemiologist would perform include overseeing research on various diseases or outbreaks (like Ebola or influenza), compiling data for publication, developing procedures or policies related to disease control in medical facilities or research laboratories, consulting with healthcare facilities, nursing homes, or hospitals to minimize infectious disease issues, help develop educational resources to minimize the spread of diseases (hand washing, wearing a seatbelt, etc.), consulting with public health department on infectious and chronic disease issues, designing and developing research studies, interpret and analyze medical data for other researchers, investigate the results of medications on patients to better understand safety and effectiveness, and working in the field to locate the source of disease outbreaks from viruses (Ebola), bacteria (Pestis), vibrio (Cholera), or zoonotic (parasites).

A clinical epidemiologist may choose to work in a field that is more specialized, for example, environmental health (pollution or environmental toxins), chronic conditions (cancer, metabolic syndrome, obesity..my speciality), infectious conditions (Viruses, Bacteria, Vibrio, or Zoonotic). Beyond these specialties, clinical epidemiologists spend a good deal of time consulting and conferring with other medical professionals including physicians, public health officials, researchers, and health administrators. Many also work in research facilities or universities, and the Centers for Disease Control and Prevention (CDC), the Federal Emergency Management Association (FEMA), the Food and Drug Administration (FDA) and other government agencies employ a large number of clinical epidemiologists.

Entomology

An entomologist is a natural scientist that studies insects. Entomologists study the classification, life cycle, distribution, physiology, behavior, and ecology and population dynamics of insects. Many work in agricultural and urban environments. Everything we know about pollinators like bees, we own to entomologists. They also enforce quarantines and regulations on certain imports, performing insect survey work, and consult on pest management. The greatest numbers of entomologists are employed in some aspect of economic or applied entomology that deals with the control of harmful insects, this includes methods of controlling insects like mosquitos while protecting beneficial insects like bees.

Perhaps the greatest entomologist of all time is Edward O. Wilson, who has written many books, among them some of my personal favorites Sociobiology: The New Synthesis (1975), On Human Nature (1978), and The Ants(1980). His most thoughtful work to date, Consilience (1998) asked some fundamental questions about science. According to Wilson, all knowledge, from the humanities to the natural sciences, can be unified. Along the lines of field epidemiology, a relatively new area of research is called medical entomology, and works with public health professionals, epidemiologists, and other medical professionals in the areas of disease prevention.

Dermatology

A dermatologist is a medical doctor that specializes in treating diseases and conditions of the skin, hair, nails, and the mucous membranes (lining inside the mouth, nose, and eyelids). Dermatologists treat over 3,000 different diseases, including skin cancer, eczema, acne, psoriasis, infections, and some autoimmune disorders.

So, in conclusion, I do work with bugs (sort of) but only those very few that cause diseases. Other than knowing that the skin is the largest organ of the body, I know next to nothing about dermatology.

I hope this clears up any confusion.