The problem was that the whole subject had become more complicated in the past few weeks as a result of a rash of new resistance cases. This time the microorganism concerned was not an Enterococcus but a strain of Streptococcus pneumoniae.
The first victim had been a twenty-three-year-old black male named Andre Nelson. A known user of cocaine and PCP—the police claimed that he was also a dealer—he had arrived at the Emergency Department after suffering an acute asthmatic attack at his home in Lynwood. Although the medical emergency team was able to stabilize him, it later emerged that he was suffering from a lung infection. That infection proved as impossible to halt as the others, and after a week on a ventilating machine Nelson had suffered complete respiratory failure. Since then, two more resistant pneumonia cases had appeared at the Willowbrook, one of them admitted via the Emergency Department, the other through General Surgery. Although it was too early to draw conclusions, Ford was convinced that the high incidence of resistant infection encountered at the Willowbrook was a cause for concern. At the very least it suggested that the selective advantage enjoyed by resistant bacteria was somehow being accentuated in the South Central community as a whole.
It was because he had felt it vital to incorporate these new cases into his speech that Ford had run out of time. If it had simply been a matter of going over the ground covered in the original article, it would have been fine—he would have been happy to discuss it with Lucy Patou. But as it was, there was no time left, and the disturbance that morning—the extra cases it had generated—had snatched away any chance of a last-minute briefing. He was going to have to deal with the Shark’s neck injury and run if he was going to make his three o’clock slot.
Ford entered OR3 and said his good-mornings. The Shark had been positioned to allow rapid, wide access to the upper thorax in the event it became necessary. He was on his back, a bolster between his shoulders, his head tilted away from Ford. Apart from the entry wound and the tube in his throat, the Shark looked as if he might be sleeping. Ford made the first long cut along the sternocleidomastoid, starting just below the Shark’s right ear. As the young man’s blood welled, he gave a little shake to get his mind off Lucy Patou, but it was impossible. He prayed that she would not find herself a front-row seat at the conference.
3
The traffic was sparse on the Harbor Freeway. Ford drove fast, listening to the news bulletins on the radio. Things had been quiet since noon, they said, but the police remained on full alert right across the city. As Central Los Angeles slid past him, street after street of squat brown houses on plots of parched brown grass, Ford could not help feeling vulnerable. He felt as if he were crossing a no-man’s land. When he saw a pair of patrol cars up ahead, he got on their tails and stayed there until the downtown tower blocks loomed tall through the gray-brown haze.
The Convention Center parking lot was the size of Dodger Stadium, but there weren’t many cars in it. Maybe the news of the disturbances in South Central had put some people off coming.
For Ford the failure of antibiotics was a more profound and disturbing threat than that of civil unrest, even if it never got a mention on the radio. For surgeons of all kinds it was a dark cloud that loomed over the future of their profession. The spread of drug resistance among more and more bacteria threatened to turn the clock back more than half a century, to the days when the most trivial infections could turn lethal and when surgery of any kind was more hazardous than Russian roulette.
Ford had been just ten years old when the U.S. Surgeon General of the day had declared that medical technology would soon be able “to close the book on infectious diseases.” At the time, this optimism had appeared well founded. As Ford later learned in high school, since the discovery of penicillin in 1928, one disease after another had succumbed to the power of antibiotics, among them scarlet fever, pneumonia, syphilis, typhoid, meningitis, and the industrialized world’s biggest killer, tuberculosis. At the same time, the ability to keep open wounds free of infection by common but potentially lethal bacteria such as Staphylococcus aureus had turned surgery from a last-ditch option to a central pillar of medicine. Unmentioned in the curriculum was the fact that, with the days of infectious disease numbered, drug companies were already devoting their resources to other health problems, in particular those afflicting the longer-lived populations of the developed world: heart failure, arthritis, and cancer.
Yet the victory had proved surprisingly short-lived. In the early 1960s penicillin-resistant strains of Shigella dysenteriae, a bacteria that causes dysentery, began to appear in Japan, killing fifteen percent of those infected. While Ford was applying for college, lethal strains of Streptococcus pneumoniae were surfacing in neonatal wards all over the world, proving fatal to three quarters of infected babies under two months of age. In South Africa a strain was found to be resistant not only to penicillin, but to most of its successors, including ampicillin, streptomycin, methicillin, chloramphenicol, and tetracycline. By the time Ford transferred to the Willowbrook in 1989, multidrug-resistant bacteria were responsible for the return of such lethal or crippling diseases as cholera, septicemia, rheumatic fever, gonorrhea, leprosy, and tuberculosis—which was claiming around three million lives a year, most of them in the Third World. Although a succession of new antibiotics had been brought onto the market, many pathogens were proving able to cope, among them Staphylococcus aureus. In many hospitals strains of superstaph, as it became known, were proving resistant to every antibiotic yet developed—except one, vancomycin.
As far as Ford was concerned, when staph overcame that final hurdle, the post-antibiotic era would have arrived.
That species of bacteria would over time acquire resistance to the antibiotics used against them was not surprising in itself. According to evolutionary theory, random changes in bacterial genes would, sooner or later, produce strains capable of surviving any given form of attack. These new strains would enjoy an enormous competitive advantage over the rest, gradually displacing them until they became dominant. What the medical profession had not anticipated was the rate at which these genetic mutations would take place: not over centuries and millennia, but over years, months, and even weeks. Even more alarming, bacteria proved capable of transmitting resistance genes between species, something unheard of in the animal kingdom. This was a particular concern in hospitals, where people suffering from different types of infection came into contact with each other via shared facilities or via the medical staff themselves. Drug addicts, diabetics, and people with AIDS—the so-called immunocompromised, who made up such a large proportion of Marcus Ford’s patients—posed the same problem in microcosm, often suffering a number of different infections at the same time because their immune systems were not strong enough to resist.
What Ford found most disturbing was the way that the misuse of antiobiotics accelerated the spread of bacterial resistance. Instead of being employed sparingly, when a patient’s natural defenses looked likely to be overwhelmed, they were still distributed en masse as cure-alls, used to tackle sore throats, toothaches, acne, and the common cold. They were fed by the kilogram to chickens and pigs and sprayed on the walls of hospital wards. In the developed world, public demand and determined marketing campaigns by manufacturers put doctors under intense pressure to prescribe the latest drugs, rather than let nature take its course. Studies in Europe and the United States suggested that between a third and a half of all antibiotic prescriptions were either inappropriate or unnecessary. In the developing world, the situation was even more serious. Driven by hunger for market share, manufacturers pushed their products as hard as possible, even though the medical profession in these countries was ill equipped to supervise their use.
Self-medication on a vast scale was the result. Ignorant of the consequences, many people would continue a course of antibiotics only for as long as their symptoms persisted and not the for the full period needed to kill all the bacteria causing them. The small colonies left behind would, of course, be th
e ones that had proved best able to cope with antibiotic attack. The cost of antibiotics, especially for the poor in developing countries, often made this false economy inevitable. But whether through poverty or ignorance, human beings had been selectively breeding for resistance bacteria just as surely as if laboratories had been set up for the purpose. In spite of this, the use of antibiotics around the world continued to grow. The National Institutes of Health had estimated that by the year 2000, a total of fifty thousand tons of antibiotics would be used on humans, animals, and plants, a mass genetic manipulation without parallel in the history of life on Earth—unplanned, unregulated, and beyond control.
The afternoon session was already well under way by the time Ford arrived. In the foyer a team of young women in scarlet jackets presented him with a name badge and a chunky document folder. On either side of the foyer stood tall displays of flowers, brilliant beneath the discreetly recessed lighting.
“We were afraid you weren’t going to show, Dr. Ford,” said a tall fifty-year-old woman with taut, face-lifted skin. Her green eyes fixed on his tie. It was on crooked; it had to be. “I’m Julia Lacey, conference manager.”
Her hand felt smooth and remarkably cold, but then the airconditioning in the center was almost enough to make you shiver. Ford realized how clammy his own hand must feel.
“I hope you didn’t have any problem getting here,” she said. “Were the directions clear?”
“No problem,” he said. “I’d have arrived sooner, but things were a little busy at the hospital. I’m sure you can imagine.”
“Yes, of course,” she said, returning him a professional hospitality smile. “Please follow me and I’ll show you to your seat.”
She led him along a passage that ran parallel with the side of the hall. Ford could hear a speech in progress, a man’s amplified voice bouncing off the walls. He felt a flutter of nerves in the pit of his stomach. The hall seemed big. Just how many people were in there? When Julia Lacey wasn’t looking, he reached up and adjusted his tie. The knot had tightened into an awkward little ball. He really needed to undo it and start again, but there wasn’t time.
Lacey opened a door giving onto a brightly lit stage. He saw a long cloth-covered table, at which sat five men in dark suits, each one with a plaque in front of him bearing his name. At the front of the stage another man was speaking at a lectern. Ford couldn’t see the audience. One of the men behind the table saw the two of them and came over. It was Marshall West, an old med-school friend of Ford’s who had recently been appointed to a top job at the county health department. It had been at West’s prompting that Ford had been invited to address the conference. Most of the speakers at conferences such as this were microbiologists and pharmacologists, experts in the research and manufacture of drugs. Surgeons, mere users of drugs, were not usually asked to participate. West had thought it a good idea to get the perspective from “the front line,” as he put it. Ford didn’t want to let him down.
Although the two men were the same age, Ford couldn’t help feeling that the years had been kinder to West. His full head of dark hair had only just started to turn gray, and there was a brightness in his eyes, a glow to his skin that suggested a healthy diet and regular sleep. Always a keen track-and-field man—he had been a champion hurdler at Michigan—he had kept himself in remarkably good shape. His tailor-made suit and crisp white shirt accentuated his athletic build. The sight of him left Ford feeling more disheveled than ever.
“Marcus, so glad you could make it,” West whispered, shaking Ford’s hand with a double-handed politician’s squeeze. “I was afraid with all the trouble you’d be snowed under. What’s happening down there? Are you coping?”
“Yes, yes,” said Ford. “We’re on top of it. Last night got pretty hectic, though. You heard about the girl?”
“I don’t think we’ll ever be allowed to forget it. The switchboard’s been jammed all day. I came down here to escape.”
“I thought the media was concentrating on the hospitals. We’ve had them camped on the parking lot.”
“Yeah, but now they’re making a big resources issue out of it, and that’s my territory.” West inched closer. “Actually, I’m wondering if it might not be helpful in the long run. I mean, this Hammel story is national news, especially with the disturbances. And national issues determine congressional votes, if you get what I mean.”
Ford nodded. Politics was West’s strong point, federal politics in particular. That was why the County Board of Supervisors had set him up above the entire administrative structure of the Health Services Department and granted him complete operational autonomy. His title was simply Health Czar. They’d hoped that with his experience and contacts he might be able to squeeze more funds out of the federal and state governments, helping to prevent the virtual dismantling of the public healthcare system in a county more heavily populated than the entire state of Georgia.
Ford and West had not seen much of each other after med school, although their careers had taken both of them from Ann Arbor to Washington, DC. Drawn to the pace and the variety of work in trauma, Ford had joined the army medical corps. West had taken up a research job for a Democratic senator named Hal Burroughs, an early exponent of healthcare reform and a friend of the West family. For a few months Ford and West tried to keep in contact, but as time went on, it had become harder and harder for both of them (as an intern, Ford’s leisure time was all but nonexistent). By the time Ford left for California, their relationship was down to Christmas cards only.
It was at his next job in Washington, at the Department of Health and Human Services, that West had acquired his reputation. In particular he was credited with a key role in an emergency response program set up to tackle an epidemic of multidrug-resistant tuberculosis (MDR-TB, as it was known). The epidemic had originally centered on prison inmates in Miami and New York City, but had spread rapidly to the general population, especially in poorer neighborhoods where drug addiction and HIV infection were rife. After extensive tests one antibiotic was found to be effective against the bacteria: streptomycin, the first antibiotic to be discovered after penicillin. But there was a problem: nobody made it anymore. Pressuring the industry into restarting mass production was a difficult proposition. Existing, profitable product lines had to be suspended to create the necessary capacity, and given the absence of patent protection, the outlook for profitability was poor. The fact that most of the demand would be in the Third World only made matters worse. It was a tribute to West’s powers of persuasion that these objections had been overcome.
The invitation from the board of supervisors came in response to another crisis, this time a financial one. The previous year, like neighboring Orange County before it, Los Angeles had been facing the prospect of bankruptcy. After four years of overspending, thanks in part to the 1992 riots and a string of natural disasters, the county found its creditors unwilling to lend it any more money. A downgrading of its long-term debt by the credit-rating agencies made the search for alternatives hopeless. The board of supervisors had no choice but to order an immediate twenty percent cut in spending so as to bring the county’s $11 billion budget into balance. In order to meet its allotted share of the cuts, the county health department was faced with the outright closure of its biggest hospital, LA County/USC Medical Center, all mental health facilities, and virtually the entire network of health centers and clinics. This network provided the bulk of immunization, pediatric, and preventative health care for the community, as well as a range of emergency services. Outpatient care was also to be radically cut. As one journalist had put it, without a restructuring plan and money from Washington the Los Angeles public healthcare system would be able to do little more than gather the dead and wounded off the streets.
By the time the invitation went out from LA, rumors had already begun that West might soon stand for elected office, although he still seemed a little young to run for Congress. Nevertheless his decision to accept had come as a surprise. The newly c
reated post of Health Czar was a political hot potato. Although job cuts and closures were inevitable, it was the czar who would play the key role in deciding where and when these should happen. It was not a job for a man who was anxious to be popular.
But West had surprised everyone. Following discussions with the President’s staff and his old colleagues at the Department of Health, he had been able to come up with extra federal funds of $350 million. The money was contingent upon the implementation of a restructuring plan that placed an emphasis on outpatient and preventive care, rather than care within hospitals, which was far more expensive. Many people still opposed what became known as the West Plan—at the Willowbrook they had received bomb threats—but most people recognized that the alternative was far worse.
Ford had finally met West again on a fact-finding visit to the Willowbrook six months earlier. Ford was struck by how little West had changed.
“What’s the turnout like?” he asked. “Has everybody stayed at home?”
“Some have,” said West, “but most of the industry people are here, and some journalists. Are you going to be okay to go ahead? Otherwise, I’ll have to say something. I’m supposed to be chairing this session.”
“I’ll be fine. I just wish I’d had more time to prepare. I’d planned—”
“Don’t worry. After Dr. van Brock and his Australian ants you’ll be a breath of fresh air. We could use a little reality check, I can tell you.”
“I’ll do my best.”
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