vulnerable versions. Dr Catherine Bennett of the University
of Melbourne grimly informs us: "Today up to 95% of the
bacteria causing common skin infections (e.g. boils) are
penicillin-resistant" (see pp.22–24).
The problem, however, is not just with the diseases.
Stephen Luntz, Editor, Issues
Chlamydia can be cured with a dose of antibiotics, but
100 million new cases (and rising) appear each year partly
because people fail to get themselves checked before passing
Inthe 1950s and ‘60s there was optimism in the air – it on.
medical science had disease on the run. Diseases like
Furthermore, rates of AIDS, chlamydia and many other
cancer might still have been a problem, but with peni-
diseases would plummet if we practised safer sex, but not
cillin putting bacterial disease to flight and vaccinations
everyone does. As Heather Corinna of www.scarleteen.com
controlling polio and small pox it seemed like only a matter
explains: "Plenty of young adults have the idea that condoms
of time before infectious diseases would be wiped out, along
put ‘something between' them and their partner" (see
with many other conditions.
pp.25–29). "A pregnancy and child absolutely puts something
Now the opposite is the case – governments around the
in the middle, as does a sexually transmitted infection." For
world are in a race to stock up on supplies of Tamiflu before
a lot of diseases the problem is not that we lack solutions, it's
an outbreak of avian influenza can cause millions of deaths.
that so many of us fail to think sensibly about using those
AIDS is killing similar numbers more slowly in the devel-
that we have.
oping world and, despite plenty of new drugs and superb
The problem is not just at an individual level. Although
public health campaigns, keeps coming back even in wealthy
no cure for AIDS exists, great work has been done to create
drugs that dramatically extend the lives of people infected with
What went wrong? The answer is many things. One
HIV. By reducing the viral load in a person's body, these drugs
problem is that many of the diseases are much more slip-
also reduce the risk that someone who is taking them will
pery than we thought.
infect everyone else.
Influenza is the perfect example. As each new strain comes
However, James Nichols of Médecins Sans Frontières
along we can produce a vaccine to protect people, but nothing
(MSF) points out: "Even today, 95% of the [AIDS] drug market
stops the disease mixing and matching its surface features to
is in the developed world, yet 95% of patients live in Africa,
find new ways past our immune systems. In most cases a
Latin America and Asia" (see pp.30–35).
new ‘flu variety does some damage before the vaccine can be
MSF's programs make antiretroviral drugs available in
created, but it is usually only fatal for those who are already
limited areas. These projects demonstrate that answers are
possible, but the failure of the rich world to provide the money
However, when a really new variety of ‘flu comes along we
has meant that the disease runs unchecked across most of
lack the immunity acquired by having encountered some-
Africa and large parts of Asia.
thing vaguely similar. If the virus is particularly potent it can
As if our neglect was not bad enough, we face the danger
kill even the strongest people, as the pandemic of 1918–19 did.
that people will deliberately choose to infect each other with
Sure we'll produce a vaccine in a few months, but ‘flu spreads
diseases as a method of war or terrorism. Stephen Leeder
so fast that tens of millions could be dead by then.
and Anne-Marie Boxall of the University of Sydney point out
Other diseases, such as AIDS resist simple vaccines in the
that biological warfare is not new. "In the 15th century, during
first place. In May 2006 the University of New South Wales
Pizarro's conquest of South America, he improved his chances
started enrolling people in a trial of an anti-AIDS vaccine.
of victory by presenting gifts to the natives – clothing laden
However, there have been plenty of vaccines tried before
with smallpox virus" (see pp.39–40).
against HIV, with little success. Even if one "works" it is more
Now, however, bioterrorism can cause chaos even without
likely to reduce infection rates a little rather than offering
killing many people. "The consequences of bioterrorism often
the almost complete protection that vaccines can offer against
have nothing to do with the biological agent used and every-
thing to do with public panic and the need for community
Even some of the diseases we thought we had beaten are
leaders to be seen to be ‘doing something'," Leeder and Boxall
reappearing as natural selection ensures that those bacteria
with resistance to antibiotics spread to take the place of the
The definition of emerging diseases is not entirely clear.
75 JUNE 2006
Some people apply it only to new and expanding infectious
So far the H5N1 variety hasn't managed to spread from
diseases, while others include any diseases that are becoming
person to person, and jumps poorly from birds to humans.
However, other flu viruses have no problems travelling from
We've used the latter interpretation, considering two
one human host to another, and flu viruses share a fright-
diseases that have increased dramatically in recent decades
ening ability to interchange DNA, so just one person infected
– asthma and RSI. Although both seem to have levelled off
with both a normal dose of flu and with the avian variety
recently they're interesting because we don't fully under-
could start a pandemic such as the one that killed more people
stand the factors that have influenced their frequency. As Dr
than World War 1.
John Woods and Prof Philip Thompson note: "The under-
For a time the world shut its eyes and pretended that the
lying reasons why some people develop asthma are still poorly
problem would go away, but recently governments and indi-
viduals have been waking up. Wealthy nations are stocking
There are other emerging diseases where our under-
Relenza and Tamiflu, two drugs that protect against, and
standing is better. Rates of Type II diabetes are shooting up,
reduce the severity of, flu.
mainly as a result of our diets and lack of exercise (see Issues
The need for such stocks is so widely acknowledged. It's
less well-known that both drugs are based on research uncov-
Sometimes we do manage to stop diseases emerging.
ering the structure of the flu virus by Prof Graeme Laver of
Variant Creutzfeld Jacob disease (CJD) appeared as a result
of people eating meat from animals with "mad cow disease".
the Australian National University. Laver identified sections
The disease attracted plenty of attention, partly because it is
of the virus' surface that don't change, enabling the produc-
so horrific and also because the infectious agent, known as
tion of drugs that prevent the virus from escaping infected
a prion, is so bizarre.
However, since it was realised that mad cow disease
However, Laver doubts that the Australian government
resulted from the truly mad behaviour of turning grass eating
will make the best use of its stores. "The plan the Health
cattle into cannibals, the disease has largely been brought
Minister announced was to use the stockpile to enable one
under control. Deaths from variant CJD have been falling
million ‘essential workers' to take Tamiflu each day for a
period of 6 weeks to prevent infection," he writes (see
The Hendra virus caused panic in the horseracing industry
pp.7–10). "This is a complete waste of a valuable drug. What
in 1994, and bouts of the closely related Nipah virus have
happens after 6 weeks, when the stockpile is exhausted and
caused hundreds of deaths in Asia (see pp.20–21). However,
the pandemic is still raging?"
a vaccine is now being tested, and it looks like we may be able
Athol Yates of the Australian Homeland Security Research
to protect ourselves against this pair before they can do much
Centre is not so damning, but he sees nine ways that the
more damage. Similarly the use of effective public health
Australian pandemic plan could fail (see pp.15–19). One issue
measures brought an end to the SARS crisis of 2003, although
that Yates doesn't mention is our heavy reliance on Tamiflu.
re-emergence is possible.
Relenza is Australian, and taxpayers invested almost
This has happened because all diseases have weaknesses.
$250 million in its development. Yet our stockpile is mostly
A disease can't afford to kill its hosts before they can infect
Tamiflu, which, while based on Australian research, was
a new host – which is why the ebola virus makes for good
horror movies but isn't likely to turn up in Sydney any time
Tamiflu has been chosen because it comes in pills while
soon. Of the 1500 people known to have been infected with
Relenza is inhaled. However, more than patriotism suggests
this terrible disease – which causes bleeding from every
that we might want to even up the balance. Widespread use
opening in the body – fatality has occurred in 80% of cases.
However, most have died too quickly to transmit the virus, and
of Tamiflu will cause the same selection pressures that see
only poor hygiene in impoverished hospitals has allowed the
bacteria become resistant to antibiotics. Having a different
number of deaths we've seen.
drug as a second line of defence may prove invaluable.
Which is why the disease that really gives experts sleep-
The government has reasons for its choices. Maybe they're
less nights is avian flu. There is a huge reservoir of birds out
the right choices, but what is really worrying is how little
there with the disease (some of which carry it without getting
debate there has been on these topics. An avian outbreak
sick), and we know how easily flu can be transmitted from
could be the greatest disaster since World War II, yet there's
one person to another.
hardly any discussion on how best to prepare for it.
RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL OF ORAL ALBUTEROL IN INFANTS WITH MILD-TO-MODERATE ACUTE HEMA PATEL, MD, MSC, SERGE GOUIN, MDCM, AND ROBERT W. PLATT, MSC, MS, PHD Objective To determine whether oral albuterol is effective in reducing symptomatology of acute viral bronchiolitisin infants with mild-to-moderate illness.
9 SOLUCIONES PARA LA SEGURIDAD EL PACIENTE: DR JOHN DOUGLAS CONTRERAS GUERRA Mg gestión y metodología de la calidad asistencial FAD-UAB "Hay algunos pacientes a los que no podemos ayudar, pero no hay ninguno al que no podamos dañar". Arthur Bloomfield (1888-1962), Profesor y Jefe del Departamento de Medicina Interna, Universidad de Stanford de 1926 a 1954