Creating Drug Resistance Close to Home: Another Example of our Broken Health Care System

Posted: 17 April 2012 in Advocacy

This post was published in a local news blog.  It is VERY context specific but I would guess that similar problems are emerging in many counties around the nation.

The Reuters news item was startling:

The WHO [World Health Organization] has convened a special meeting on Wednesday [March 21, 2012] to discuss whether the emergence of TB strains that seem to be resistant to all known medicines merits a new class definition of “totally drug-resistant TB”, or TDR-TB.

If so, it would add a new level to an evolution over the years from normal TB, which is curable with six months of antibiotic treatment, to the emergence of MDR-TB [multi-drug resistant], then extensively drug-resistant TB (XDR-TB).[1]

In the event, the WHO decided not to add this new class due to a lack of information. And while TB has declined over time in the US and is, according to the Centers for Disease Control[2] at its lowest level since 1953 (when national reporting began), it is on the rise in Great Britain (according to Reuters) and the extensively drug resistant strains are emerging in prisons and poor populations around the world.

It is important to note that the emergence of these strains is not part of the natural evolution of the TB bacterium but rather as the Reuters’ article notes:

What’s so frustrating about that progression, says Lucica Ditiu of the WHO’s Stop TB Partnership, is that all drug-resistant TB “is a totally man-made disease”.

Dr Ditiu is referring to improper or incomplete treatment regimens that help spawn drug resistant strains. TB treatments can take 6 months or more to complete and in simple terms, taking a partial treatment has the effect of “killing” the “weakest” forms of the bacterium and allowing the “strongest” to survive and propagate more resistant strains.  Essentially, this is how drug resistant strains of a bacterium (or a parasite as in the case of falciparum malaria) are created.

TB is not (nor is malaria thank goodness!) a major concern for Davis or Yolo County at this time but, arguably, the practice of medicine for the “indigent” populations in Yolo County is creating risks that more resistant strains of bacteria will emerge in this county.  Yolo County does have a health care program for our poor and homeless called YCHIP: Yolo County Healthcare for Indigents Program. This is not to say that YCHIP is a failure but it is being stretched and the treatment options for poor or indigent people are often not conducive to creating healthy outcomes and do run the risk of helping create drug resistant strains.

A recent case illustrates this point: “M”, a homeless individual living in Davis, contracted pneumonia in January of this year.  M was fortunate enough to spend dry nights in one of the several shelters provided by a variety of providers in Davis, however, he spent his days trying to stay out of the inclement, wet weather.  It is important to note that YCHIP recipients can access a clinic behind Sutter Hospital (Communicare) during the day without an appointment, and wait in hopes to be seen. Unfortunately M’s symptoms became severe after the clinic had closed down leaving him no other option than the Sutter Hospital emergency room one evening when he experienced a worsening cough and shortness of breath

At the ER he was diagnosed with pneumonia and given a partial course of treatment with a standard antibiotic. By partial course I mean that he was given the initial dose, which is enough for the initial first day of a 5-day treatment.  He was also given a prescription to obtain the remaining 4 days of treatment at a pharmacy.

It is not common knowledge, perhaps, among Davis residents that there is NO pharmacy in Davis that currently accepts YCHIP client prescriptions. Rumors among homeless individuals are that the Communicare Clinic will soon be filling prescriptions). As a result, M, who was sick with pneumonia, was required to take two buses to arrive at the pharmacy at Raley’s in Woodland that does accept YCHIP client prescriptions.

There is a great deal wrong with this story and it leads to several questions: 1) Why would a health care provider provide part, but not all of an anti-biotic treatment knowing that the use of partial treatments can lead to drug resistant strains of bacteria? 2) What if M had been too sick or lacked the resources to take the bus to Woodland? 3) Why has there been no pharmacy in Davis for YCHIP clients for several years?

Discussions with homeless individuals reveal that the experience of M is not unusual. In addition, any poor or homeless individuals in our community can relate stories of not only walking significant distances to get to a health care clinic and, at best, hoping to be seen only then needing to take buses to the Woodland pharmacy while seriously ill in order to obtain appropriate medications.

A few issues in this story should concern us all. While some may question the value of the YCHIP “welfare” program believing that homeless (especially!) populations find themselves in their situation because of bad choices or various addictions, we should keep in mind that drug resistant strains that can emerge with the inappropriate and partial treatment practices described above affect all of us.  Say what you will about homeless individuals (and I have heard a great deal that is disturbingly dehumanizing of this diverse group of human beings), their health, or lack thereof, is tied to your own.  In the end, caring about the appropriate use of medications by the poor (or the rich for that matter) has nothing to do with empathy for their plight and everything to do about self-interest.

You might say that “M’s” case is a single anecdote and an aberration.  Perhaps it is.  But not according to the many poor and homeless individuals with whom I interact on a daily basis. As a community we can’t afford to be ill informed about the treatment options available to our poor neighbors.  This is not a call for any particular form of health care but rather a plea for us to acknowledge the need for more community conversations about how health care is dispensed in our County.  I am talking about primary health care here—the basic level of care that helps people, should they choose or need to access the system, deal with regularly occurring illnesses like acute respiratory infections, skin infections and food borne illnesses, to say nothing of the complications of their untreated mental health.

[1] http://www.reuters.com/article/2012/03/19/us-tuberculosis-idUSBRE82I0D820120319

[2] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm

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