West clapped him on the shoulder.
“Knew I could count on you. We’d better go.”
He led Ford to an empty place behind the long table and resumed his own seat in the middle. At the lectern Dr. van Brock, a tall man with a neatly trimmed beard and a Teutonic accent, was delivering the conclusion to his speech. According to the program, it was entitled “Anti-infectives in Nature—Alternative Strategies for Research.” In front of him sat an audience of maybe one hundred and fifty people, although the auditorium was designed to hold three times that number.
“Over the years we have come to think of antibiotics as an invention of modern science,” he was saying, “the sole purpose of which is to protect human beings and livestock from bacterial infection. We forget that antibacterial defenses were developed by bacteria themselves long before the evolution of plant or animal life on Earth. The weapons developed by certain species of fungus were the basis for the earliest antibiotics, including, of course, penicillin.” He spoke directly to the audience, not even glancing at his notes. “What I hope our work on the Formicidae of Australasia will demonstrate is that the antibacterial struggle has also been waged by more complex species, including that most diverse class of species in the animal kingdom, the Insecta. Research into their antibacterial strategies may provide us with some exciting new insights in the years ahead.”
He gathered his papers and acknowledged the audience’s applause with a smile. In spite of what West had said, Ford got the impression that the audience liked Dr. van Brock and his work. He had a reassuring, avuncular manner, like one of those Middle European professors that always turned up in old sci-fi movies. And maybe he was really onto something. Maybe there were useful lessons to be learned from the insect world about how to deal with microbes. It had to be worth a try, if only because, during the past few years, conventional pharmacological research had come up with very little that was new.
West was on his feet, thanking Dr. van Brock, when Ford saw her sitting in the second row—Lucy Patou. She was looking straight at him, her upturned head accentuating her smooth jawline and high cheekbones. He felt the color rise to his cheeks. She thought he’d been deliberately avoiding her, and now she was down here at the conference, watching him like a member of the health department Thought Police. A man sitting next to her leaned over and whispered something, and she smiled. Ford thought about giving her a wave, trying to ease the tension a little, but he had a feeling she wouldn’t wave back. Loulou Patoulou was onto him.
He got through the first part of his speech pretty well, summarizing the work of the Willowbrook’s Trauma Unit and the type of community it served. A grim silence descended upon the audience as he described the high proportion of patients who were on welfare, and the growing number of so-called undocumented people—mostly illegal immigrants from Mexico. He hammered home the point that many of these people had virtually no other contact with professional health care, either because they lacked any form of insurance coverage, or because they simply did not know how or where to get it. Many of them showed clear signs of malnutrition, a proportion comparable, in fact, to that in many developing countries. This was as true for the children as for the adults—and children now made up around a third of the Willowbrook’s trauma admissions.
He made sure there was no trace of emotion in his voice. He didn’t want his speech to sound like a charity appeal or, worse still, a political call-to-arms. He was setting out the parameters of his experience, not appealing to anybody’s conscience. Even so, as he went on, he sensed a growing restlessness, an embarrassment. Maybe it was just his imagination, but it was something he’d become sensitive to over the years. When he talked about his work to neighbors and old friends—prosperous middle-class people, with careers and families—he had often felt the same thing. For them, hearing about South Central and its problems was like being told about another famine in Africa as you sat down to your evening meal. You felt guilty, not because you were responsible, but because you knew damn well you weren’t going to do anything about it.
He avoided Lucy Patou’s eye as he moved on to the incidents of drug-resistant infection he had witnessed during the last year: first the Enterococcus and then Streptococcus pneumoniae. This was her field, and the certainty that she was keeping track of his every word made it harder for him, but he described each case in detail: the progress of symptoms, the tests carried out, the treatments attempted. He also described how, in each case, a thorough search of the Intensive Care Unit and its equipment had been carried out to see whether the source of the infections was nosocomial—originating inside the hospital itself.
“Since these searches came up negative,” he said, “I think it fair to assume that an uncommonly high incidence of resistant bacteria now exists among the South Central population, and perhaps beyond. There are a number of possible explanations for this, but high among them has to be the lack of supervision in the distribution and use of antibiotics. That is why I believe resistance is, at least in part, a resources issue.”
Several people shifted in their seats. Lucy Patou’s arms were now folded, and she was perched on the edge of her seat, as if struggling with an urge to interrupt. Ford ploughed on: “But lack of resources here in the U.S. may only be part of the problem. More than twenty years ago a strain of Salmonella typhi, the microbiological cause of typhoid, killed hundreds of people in Mexico and threatened to spread into this country. A U.S. Senate committee investigation concluded that the bacteria had mutated into a superbug because the drug industry had aggressively promoted chloramphenicol for a wide variety of infections in Mexico and other developing countries. That early warning does not seem to have been heeded. Latin America today plays host to an alarming number of resistant pathogens, including the El Tor strain of Vibrio cholerae, which is now carried by at least a million people in the Western Hemisphere and has killed at least nine thousand to date.”
Ford looked up from his notes. In the audience people were exchanging glances. Ford wondered what it meant. It couldn’t be that they were surprised at the information—the outbreaks he’d referred to were well known and well documented—but for some reason they seemed surprised to be hearing it now, as if it somehow had nothing to do with them. Ford felt his pulse accelerate. He had to stick to the argument, get to the point. Maybe he was simply going on too long. He turned over a page of his notes, but found himself looking at an abbreviated version of his opening remarks.
“What I want to say…”
Someone in the audience cleared their throat. Ford turned over another page. It was upside down.
“What I want to say is simply…”
It was another part of the speech he’d already done. He’d dropped some pages somewhere or left them at the office—or … Then he remembered: they were still on the microcassette recorder.
He looked up at the audience, at the rows of upturned faces. One hundred and fifty people. Industry executives, healthcare experts, biotechnology entrepreneurs. Professional people, successful, civilized. They sat there in silence, waiting politely for him to have his say, to get his lungful of the clean, cool, civilized air before returning to the inner city, to a world of violence and barbarism that they had despaired of long ago. They were probably wondering where he’d gone wrong.
“The point is this: we can go on looking for new drugs, magic bullets to tackle each new crisis, but that’s what we’ve been doing for the last twenty years, and it isn’t working.”
He saw several heads pop up around the auditorium. Suddenly people wanted to get a look at him.
“We’re not winning the war. Sure, we need new antibiotics urgently, but the way things are going at the moment, the bugs are developing defenses faster than we can develop weapons. What’s the use of coming up with new products, new approaches, if two years down the line they don’t work anymore?”
There was an audible murmur from one side of the auditorium. Maybe in front of a conference of pharmaceutical producers this line of argument s
eemed a little hostile. Suddenly Ford felt hot.
“I realize that the drug companies are businesses. They have to sell their products. But there’s a conflict here: the more widely their products get used—I mean in the antibiotic field—the less effective they become. Mass distribution might be profitable in the short term, but the resistance that results may pose a threat to all of us. Microbes don’t care about borders any more than they do about race or … income.”
Ford glanced round at Marshall West: his face wore an expression of muted surprise mixed with amusement.
“This conference is about priorities for medical R and D, and you’ve asked me to give you the view from the intensive care unit. Well, for the R and D, priority is to change the way these drugs are handled. Yes, I want to see more resources put into health care—what surgeon doesn’t? I want to see more independent information made available about drug-resistant infections, so that at least we know what to expect. But most of all I want to see much closer control of how and where antibiotics are used. It may not be a fashionable word, but what I’m talking about is government regulation, of sales, of exports, whatever it takes. Given what we now know, I think that’s the logical next step. If hospitals like the Willowbrook are to go on saving lives as they do now, I don’t see any alternative.”
Ford gathered up his notes. He’d planned on sounding more professional, less strident. He’d planned on presenting a step-by-step argument, instead of galloping to the end the way he had. But it was too late now. From the audience came a hesitant spatter of applause.
“Thank you very much,” he mumbled and turned to go, but immediately Marshall West was on his feet.
‘I’m sure Dr. Ford will take questions. Would anyone…? Yes, sir.”
A smartly dressed man with ash gray hair and heavy-framed glasses stood up. He was handed a microphone by one of the young women in the scarlet jackets.
“Ed Sampson, Biofactor Research,” he said. His voice was gruff, with a faint southern drawl. “Dr. Ford, surely you don’t expect pharmaceutical companies to be responsible for controlling the way drugs are prescribed in the Third World. How do you expect us to do that?”
It was an obvious objection, and one that Ford had anticipated.
“Well, I think the reality is that pharmaceutical companies, and their local representatives, will sell their products as aggressively—and, if I may so, irresponsibly—as the local conditions allow. Chloramphenicol in Mexico was one clear illustration of that, and I don’t believe very much has changed. What’s more, when developing countries have tried to set up centralized and rationalized distribution systems, these have been opposed by the major drug companies as an infringement of their free-market rights. In fact, our government has on occasion threatened to withdraw aid from Third World countries whose drug policies it considers overly restrictive. I’m not an expert on the drug industry, or any kind of industry come to that, but as a doctor it seems to me that if companies cannot or will not ensure that their products are used appropriately in a given country—and will not let anyone else do it for them—then they must refrain from distribution in that country altogether.”
There was a murmur of dismay from the audience. Several more hands went up, but Ed Sampson was not finished: “Dr. Ford, Pharmaceuticals is a competitive industry. It has investors, shareholders, employees. Doesn’t it worry you that even more government regulation would simply kill off any incentive for companies to spend money on research? What with the time it takes to get drugs approved by the FDA, it’s getting harder and harder to justify R and D spending as it is. I mean, this is shareholders’ money. And they need to see a return sometime, don’t you think?”
The rest of the audience seemed to like this question, if it was a question.
“The profit motive is important, I’m sure,” Ford replied. “But a profitable drugs industry doesn’t necessarily mean a … a healthier world. Over the past thirty years there’s been a massive increase in the consumption of medical drugs, yet I see no real improvement in public health. In fact, here in the U.S.A. our infant mortality rate is now the highest in the developed world and the incidence of chronic infection is rising all the time. If we look at the global picture, the industry’s record is even worse. By the time drug-resistant tuberculosis hit the U.S.A., three million people a year were already dying of the disease in the Third World, yet the one drug that was still effective against the bacteria had gone out of production.”
Marshall West was nodding slowly, no longer smiling, but watching Ford with an unfamiliar intensity.
“Like you say, sir, Pharmaceuticals is a business. It devotes its attention to the most lucrative markets: people with money to spend, people who are willing to pay top dollar for the latest products. But it ignores the interests of everyone else—the majority. Because it is they, the poor, who are least able to deal with the new generation of resistant pathogens. I worry that this—how can I put it?—this narrowness of focus may come back to haunt us.”
Sampson did not look happy, but West was moving things along: “Another question? Yes, sir. In the second row.”
It was the man who had been talking to Lucy Patou. He had short blond hair, glasses, and a bow tie. The way he smiled gave Ford a bad feeling.
“John Downey, Jr., Mirada Technologies, Dr. Ford,”—he held the microphone in one hand and kept the other deep in his trouser pocket—“as I understand it, your view is based upon the experience of the cases you’ve handled at the Willowbrook, the cases you’ve described today.”
“That’s correct,” said Ford.
“You believe that more resources, more medical supervision, and tighter government regulation of the pharmaceuticals industry would prevent such cases from arising. Is that right?”
“I think it would help, yes.”
“Yes”—Downey rocked forward onto the balls of his feet, seeming to ponder the issue for a moment—“I see. But as I understand it, Dr. Ford, most of the cases you describe concerned addicts, narcotics dealers in fact, people who wantonly abused and weakened their systems with heroin, PCP, and the like. Of course, the fact that you and your colleagues devote yourselves to the care of such people is commendable, but is it right, do you think, to overturn the whole industry, at huge cost, to protect the well-being of people who seem to have little or no regard for it themselves?”
John Downey, Jr., was suddenly the most popular man in the room. All over the audience people were nodding and muttering their agreement. Several people in the audience actually clapped.
“A patient is a patient,” Ford stammered. “It is not my job to discriminate between … Besides, the fact that some of these particular individuals may have been immunocompromised does not alter the fact that the bacteria infecting them proved resistant to a wide spectrum of antibiotics, possibly all antibiotics. It is only to be expected that the immunocompromised among a community would succumb to infection ahead of the rest.”
People had started talking. At the back a couple of people walked out, buttoning their jackets. More arms were going up. Ford felt as if he were drowning. Suddenly West was on his feet again.
“On the question of cost, I would just like to add one point,” he said calmly, waiting a moment for the silence to return. “Studies have shown, both here in the United States and elsewhere, that close supervision of patient medication can be done cheaply and is actually cost effective. First, it generally results in fewer and cheaper drugs being prescribed. Secondly, it may prevent the creation and spread of the kind of resistant strains Dr. Ford has described. To give you an example of the economics involved: in the mid 1980s both federal and state administrations slashed their budgets for tuberculosis control and surveillance, saving I believe two hundred million dollars in all. A few years later we were hit with an MDR-TB epidemic, which cost at least one billion dollars to rein in via an emergency response program, not to mention the cost in lost productivity and human lives.”
John Downey, Jr., was alread
y sitting down.
“That is why,” West went on, “here in Los Angeles County, we have set up what we call a Directly Observed Therapy, or DOT, program in spite of our very tight financial position. Yes, it is relatively labor intensive, but we believe it makes good sense in the long run. So, while I take the gentleman’s point, I think the cost issue is, at the very least, open to debate.”
He looked around the auditorium. Suddenly no one wanted to ask any more questions. Debating with a South Central surgeon was one thing, with Marshall West quite another. Ford had the feeling he had just been rescued from the schoolyard bullies by the deputy principal.
“Now, if there are no more questions, I think we’re due for a break,” West said. “I suggest we continue this session at four.”
They were serving tea, coffee, cold drinks, and pastries. The networking was back in full swing, taking up where it had left off at lunch. Ford eased his way through the crowd, catching one solitary nod of acknowledgment. He helped himself to coffee and scanned the room for a friendly face. West had disappeared and he recognized no one, except Lucy Patou. She was over by the door, talking to John Downey, Jr., laughing in a lazy, distracted way. Ford didn’t want to talk to her, but it was only going to make things more awkward if he ignored her. He took a mouthful of coffee and started making his way over.
“Excuse me. Dr. Ford?”
Ford turned and found himself facing a tall man, maybe sixty years old, with deep-set brown eyes. There was no name badge on his lapel.
“I just wanted to tell you … what you said, it interests me very much. I read your paper on the Enterococcus. It’s … It’s rare to find a surgeon who’s so … who’s alert to these issues.”
He spoke quietly, almost nervously, as if he didn’t want to be overheard.
“My name’s Novak. Charles Novak.”
“Yes, of course. Professor Novak. I read your paper in Science last year. It really got me thinking about this issue.”
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