Should We Be Afraid of the Superbug?

A mysterious infection-breeding gene is sweeping the world -- or possibly just cable news.

For a few days this August, much of the news media in the West became convinced that we were headed back to the 1800s, medically speaking. A study in the September 2010 issue of British medical journal the Lancet argued that bacteria carrying genes for NDM-1, a gene that imparts resistance to a key family of antibiotics, had made their way through India and Pakistan into Britain and were now threatening to derail medical treatment across the developed world. Linked with the always shady-sounding concept of "medical tourism" -- the practice of traveling to other countries for budget surgery -- the so-called "superbug," able to breed vicious and deadly infections, became an instant media panic during a slow news month. The Drudge Report and Andrew Breitbart's news website both featured it. A Guardian science columnist wrote, "Now, the post-antibiotic apocalypse is in sight."

Er, not so much. As with most August stories, the reality of superbugs is a bit more complex than the media has portrayed it. Yes, antibiotic-resistant bacteria are a threat, as this week's news of an outbreak among premature infants in London reminds us. But no one yet knows how bad NDM-1-related infections could be. Not only is it far too early to say we're headed for apocalypse, we've also got a lot to learn from superbugs -- namely, how our own over-use of antibiotics is making it more likely that a superbug of the future could live up to this summer's hype.

Alexander Fleming discovered the first antibiotic by accident in 1928, when he left out a bacterial culture for a month while on vacation and came back to find that some of the bacteria had been killed by a fungus named Penicillium. By the early 1940s, a commercial product, penicillin, was mass-produced to cure bacterial infections in humans, and medical practice hasn't been the same since.

These days, antibiotics are a major weapon in medicine's war on disease, used to treat everything from life-threatening infections like meningitis to more run-of-the-mill ear infections. For more advanced medical technologies, like chemotherapy or organ transplantation, antibiotics are needed to prevent and treat infections while patients heal. Neither treatment would be possible without antibiotics.

At this point, in fact, antibiotics are suffering from their own success. They are so engrained in the medical and social culture that over-prescription is a major problem. Recent surveys have found that 70 to 80 percent of doctors' visits for sinus infections result in an antibiotic prescription. But most sinus infections are caused by viruses, and antibiotics don't cure viral infections.

The medical sin of antibiotic overuse goes beyond mere ineffectiveness -- it actually can be harmful. Here's how it works: Bacteria are everywhere on our bodies, even when we are not sick. When we take antibiotics for a bacterial infection, they only kill certain bacteria (usually the ones making us sick). Then, as the body gets better, the surviving bacteria multiply and take over. Now and then a few remaining bacteria carry special resistance to antibiotics -- which is what kept them alive in the first place. With the other bacteria out of the way, the resistant bacteria (i.e., the superbug) can multiply and sometimes cause problems. For example, if one of those superbugs causes an infection, some antibiotics won't work anymore, and then you have an infection that is more difficult to treat.

One of the prototypical superbugs caused by antibiotic use (and overuse) is Methicillin-Resistant Staphylococcus aureus (MRSA). MRSA is resistant to many antibiotics, including penicillin, and causes a variety of problems in humans: mostly skin infections, but also more invasive diseases like pneumonia and bloodstream infections.

Another superbug that's been around for a while but has also taken a recent media tour is Clostridium difficile (C. diff), which can be spread when antibiotics wipe out normal intestinal bacteria that keep C. diff in check. A recent study found C. diff infection occurred in 13 out of every 1,000 hospitalizations. C. diff causes diarrhea, and in some cases a particularly severe and sometimes lethal infection of the colon.

Looking at bacteria carrying the NDM-1 gene, C. diff, and MRSA, it's not surprising that people would panic over the possibility of these or other, even more resistant, bugs of the future making our advances in antibiotics worthless. And it's a legitimate fear. Although there are antibiotics and other treatments that work against all known superbugs, bacteria will continue to evolve, developing stronger antibiotic resistance in the future. It is conceivable that bacteria will someday outsmart our best medical technologies.

But it is unlikely that it will happen any time soon. One reason is that there are many different classes of antibiotics, so while some don't work against superbugs, there are usually others that do. Antibiotics that have been shelved for years might even be re-introduced to fight superbugs, though obviously this would be less than ideal because of higher risk of side effects. A better and more likely solution is for drug companies and other scientists to discover new classes of antibiotics. The financial incentives for heading off a true superbug-led medical catastrophe would be huge -- something that always drives medical innovation quite nicely, as it did with treatments for HIV in the 1990s.

Beyond praying for technology to catch up with biology, however, we also need to cut back on the over-prescription of antibiotics, ideally by giving doctors incentives to adhere to standard treatment guidelines. The National Quality Forum has recently endorsed a measure requiring physicians to stop prophylactic antibiotics used during surgery within 24 hours of the end of the procedure, ensuring that people stop getting antibiotics when they stop needing them.

These sorts of measures need to happen everywhere, not just in the United States or in the developed world. Reducing the spread of superbugs in only one part of the world is likely to be ineffective because the ease of global travel and medical tourism can spread superbugs bred in Bangladesh directly to Boston in a matter of hours. So creating stricter standards for antibiotic use in the many countries where patients can bypass doctors and buy antibiotics over the counter from pharmacies would be crucial.

Like the MRSA panic of last summer, this year's superbug frenzy, too, will die down. On the scale of media-freak-out irrationality, superbugs have more credibility than the Large Hadron Collider apocalypse, for example, but they're not even up there with swine flu.

Ultimately, as with most such overreactions, the real solution is to give some calm thought to the serious problems behind the panic -- in this case, over-prescription of antibiotics -- and then just be glad it's September.

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Contested Settlement

Obama is trying to broker a quiet compromise on the issue of Israeli settlement construction -- but it doesn’t seem that the Israeli far right is willing to play ball.

Israeli settlement construction in the occupied Palestinian territories has proved to be among the most serious irritants in the U.S.-Israel relationship. It is also one of the most significant obstacles to a negotiated settlement. But with direct Israeli-Palestinian negotiations kicking off this week and Israel's partial settlement freeze set to expire in a few weeks, the issue is once again poised to come to the forefront of the Middle East peace process.

President Barack Obama's administration has already found itself entangled in this issue twice this year -- first when Vice President Joe Biden visited Israel in March, and again when Israeli Prime Minister Benjamin Netanyahu visited Washington later that month. In both cases, Israeli officials announced controversial settlement projects in Palestinian areas of occupied East Jerusalem in a manner that was deeply embarrassing to the Obama administration. During his Israel visit, Biden condemned the settlement construction as "precisely the kind of step that undermines the trust we need right now" in one of the most public manifestations of the perceived rift that had emerged between the United States and Israel since Obama's inauguration.

Israeli settlement construction is also rapidly climbing the ladder of Palestinian concerns. Palestinian leaders vividly recall the long years of negotiations in the 1990s, during which the number of Israeli settlers doubled from 200,000 to 400,000, and now have almost reached half a million. The Palestinian nightmare is that additional years of fruitless talks will provide a stable environment for another major expansion of settlements, which would permanently foreclose the creation of a viable Palestinian state.

From his first day in office, Obama attempted to launch a major effort to restart Israeli-Palestinian negotiations that would begin with an Israeli commitment to freeze all settlement activity. Netanyahu, however, deftly shifted the subject from the West Bank to Jerusalem, on which he had much more support from members of the U.S. Congress and in Israel. In response to U.S. pressure, he issued a partial, 10-month moratorium on settlement construction, which did not include Jerusalem and contained many loopholes, such as the grandfathering of no less than 3,000 settlement housing units deemed to have been started before the freeze began on Nov. 25. This allowed Netanyahu to successfully triangulate between U.S. concerns and the demands of his right-wing coalition partners, but the moratorium will expire on Sept. 26, forcing the prime minister to find another method for remaining in both sides' good graces.

After spending most of last year attempting to get Netanyahu to agree to a complete settlement freeze, the Obama administration came to the belief that the contentious settlement issue was toxic for U.S.-Israel relations and an impediment to the resumption of direct talks. Obama effectively took the issue off the table following the U.N. General Assembly meeting last fall, when he declared that the United States still regarded further settlement activity as illegitimate, but was now focusing on restarting direct negotiations.

The Palestinians, having adopted the U.S. demand for a complete freeze, consequently were placed in an impossible situation. Palestinian Authority President Mahmoud Abbas, after all, was unable to back down on this demand as easily as Obama.

To restart direct talks, the Obama administration therefore needed to find a formula that would allow the Palestinians to return to direct negotiations without a complete settlement freeze. Furthermore, any deal needed to strike a compromise that would prevent the talks from collapsing following the Sept. 26 expiration of the partial moratorium.

Many informed observers have suggested that Obama and Netanyahu reached a private and tacit understanding to resolve this conundrum during the Israeli prime minister's White House visit on July 6. The two leaders may have reached an agreement that Israel need not extend the moratorium but that Israel will still, in practice, restrict building to Jewish areas of Jerusalem and large settlement blocs in the West Bank. These areas are understood by all parties to be the likely subject of a land swap in the event of a final-status agreement. Obama and Netanyahu's deal, as long as it remained unspoken, would preserve Netanyahu's viability with his domestic right-wing constituency while also preventing new land expropriations or incendiary projects in Arab areas of Jerusalem from derailing negotiations.

With the Aug. 20 announcement that direct talks were set to resume, it appeared that all sides were prepared to live with such an arrangement. However, several spoilers on Israel's far right have emerged to try to kill the understanding by making it public. Interior Minister Eli Yishai, Foreign Minister Avigdor Lieberman, and dissidents within the prime minister's own Likud party have strongly opposed any such arrangement and hinted that Netanyahu had privately accepted this formula.

As early as Aug. 11, Yishai told the Jerusalem Post, "I believe that [Netanyahu] will resume building only in the blocs as a gesture" and said he opposed and would try to block any such de facto policy. The same Jerusalem Post article cited sources close to Netanyahu as saying that one of the appeals of such a policy is that it would satisfy both the Labor and Likud parties and that "Netanyahu had made a point of planting trees… in three 'consensus' areas: Ariel, Ma'aleh Adumim and Gush Etzion," suggesting this policy was already being observed in practice.

These strong Israeli public statements on settlements prompted an inevitable but ill-advised Palestinian reaction. On Aug. 23., chief Palestinian negotiator Saeb Erekat made a pronouncement that any resumption of settlement building would lead to a Palestinian walkout from the talks, saying that "Israel has a choice: 12 months of peace, or settlements and no peace. They cannot have both." President Abbas has suggested several times that an extended settlement freeze was once again a precondition for the continuation of negotiations, though that is going to be an extremely difficult policy for the PLO to follow in practice, given the diplomatic costs such a move would entail, especially with regards to its relations with the Obama administration.

For now, Netanyahu appears to have been able to hold off the right-wing offensive. Yet, this episode highlights the pitfalls that the Obama administration will face on the settlements issue as it tries to push negotiations forward in the future. There is a very powerful constituency within Israel -- including within the state bureaucracy -- for settlement expansion. Many observers argue that the pro-settlement constituency in Israel is one of the most effective in the country -- permeating the bureaucratic apparatus that makes day-to-day decisions on settlement construction and using the mechanisms of Israel's parliamentary system to act as kingmakers for prime ministers like Netanyahu who can ill afford to confront them. More importantly, no Palestinian leadership can make the painful compromises necessary for peace while Israel undertakes major settlement expansions.

Both sides can theoretically gain sufficient diplomatic space for the talks to proceed by agreeing to a formula in which Israel only builds within areas generally understood by all parties to be the likely subjects of a land swap. However, it is an open question whether Israel's society and its government are capable of restraining themselves in this manner when such a significant constituency regards settlement expansion as an essential and even sacred duty. As Foreign Minister Lieberman put it on Aug. 25: "There is no reason to continue to freeze settlement.… We've done enough and we got nothing in return."

The Obama administration will need to devise some method for containing the damage from this uncompromising Israeli posture, regardless of the Sept. 26 moratorium expiration. If it is unable to broker a compromise that satisfies its own concerns and that of the Israelis and Palestinians, it will be widely seen in the Middle East as a failure of both U.S. leadership and, more specifically, for the president himself. While the negotiations may or may not survive such a failure, it would be an extremely disturbing omen for the president's ability to broker an Israeli-Palestinian agreement and, more broadly, to succeed in his very ambitious agenda throughout the region.

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