American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, March 15, 2016

On beyond Zika

Like everyone else who has heard the news about it, I find the rapid spread of the Zika virus extremely alarming. The newly recognized capacity of this virus, which historically has caused mild, self-limited infections in adults, to induce microcephaly, a terrible birth defect, is nothing less than devastating. To date, Brazil has borne the brunt of this development, with thousands of newborns affected. But the virus has now been identified in at least 20 countries in the Americas. As I write this, the World Health Organization is scrambling to catch up with the global proliferation of this emerging infectious disease, and poised to declare a public health emergency.

As inevitably occurs when a new health threat emerges, this one is generating lots of media attention, with coverage in both the scientific literature and popular press. Predictably, much of that attention is specific to the Zika virus itself, with relatively less addressing the general circumstances that foster our vulnerability to such crises. Both topics matter.

This particular virus was originally identified in Uganda some 70 years ago, first in monkeys, then in people. That likely makes it a zoonosis at the start, a disease transmitted to our species from another. The vector shuttling between the two was the Aedes mosquito, the bite of which transmits the virus. The first human who got Zika, in other words, was likely stung by a mosquito that had drawn blood from an infected monkey not long prior. For the past half century, Zika has generally been limited to Uganda and Tanzania, with isolated outbreaks seen occasionally in other parts of the world.

That there is no specific treatment for Zika, named after the forest in Uganda where it was first identified, and no vaccine, is because until now the virus has not inspired much global concern, partly because it was not all that serious, and partly no doubt because it was “over there.”

Exactly why this infection, in the same family with the viruses that cause yellow fever and dengue fever, is suddenly implicated in an epidemic of birth defects is a work in progress. One likely explanation, for which there is evidence, is an evolutionary change in the virus itself. That may be compounded by exposure of new human populations, with perhaps different genetic vulnerabilities; transmission at a new scale; or other factors yet to be determined. We are currently on the steep part of the learning curve, racing to catch up with current events.

That's a familiar race. We ran it for Ebola, too; and SARS, and MERS. Whatever the next outbreak is, we will likely need to run it again. We keep getting left behind.

For now, practical advice about Zika is limited, and mostly of the “easier said than done” variety. Countries mired in the outbreak are advising against pregnancy. We are all encouraged to avoid mosquito bites. Travel advisories are being issued.

As we confront Zika, but mostly fail to think beyond it, I am tempted to compare this predicament to its analogy in the space I work in all the time, nutrition. For decades, we have shifted from 1nutrient fixation to the next. Fat, carbohydrate, sugar, gluten, and generally been left behind by the big picture. The result has been a flurry of misguided, mono-nutrient activity, and no meaningful improvement in our prevailing vulnerability to the marketing of junk food. We just keep encouraging the invention of new varieties of junk food, and reaping what we sow. At present, we have sown a bumper crop of gluten-free junk.

The situation with emerging infections is much the same. We react to each as if the particular bug is the entire problem, while paying far less attention to fundamentals of public health practice and preparedness that account for vulnerability not just to the last outbreak and the current one, but the next. That same tendency—the neglect of public health until we have cause to think about panic, outrage, or both—is on display in Flint, Michigan as well.

The implications of the Zika crisis are not confined to this particular pathogen, for there will be a next, and a next. I am reasonably confident that an acute concentration of resources and ingenuity on Zika will result in a vaccine. Welcome though that will be, perhaps even by some prone to misguided railing against vaccination, it will do nothing to resolve our basic vulnerability.

As the climate changes, and we are past the point of debating the fact of it, the distribution of pathogens is changing too. We have seen this many times already, and are thus forewarned: we will be seeing it again. Whether or not we are forearmed depends on how we react, and allocate resources.

There is, thankfully, ever more attention to how the more than 7 billion of us Homo sapiens are roughing up the planet's remaining pristine places. There is less, however, to the ramifications of it. For one thing, more people in more places inevitably means more encounters with bugs formerly unencountered. For another, the disruptions of ecosystems often circle back to bite us.

Another issue, relevant to almost every major peril our species now faces, is the very fact that there are more than 7 billion of us, and rising fast. There aren't just humans in ever more places, there are ever more humans in ever greater concentrations everywhere. Whatever else we may be, we are just one, vast Petri dish to our pathogens. Plagues are a product of dense populations and unprecedented population densities will predictably mean new plagues.

And then finally, there is our proclivity to disperse into our competing factions: nations, religions, political parties, and so on. The distinctions between “us” and “them” may matter enormously to us, and them, but to the Zika virus, we are all the same, accommodating species. From the bug's eye view, there is no “over there.” In a world of increasing global travel, the bug is right.

In our fantasies, we acknowledge that. The usual scenario is a science fiction adventure in which humanity is attacked by a scourge from without by an extraterrestrial menace, and that common threat provides common cause, and unifies us. We overcome our differences to defend our home, and our shared humanity.

From what we know about the universe, the probability of extraterrestrial visitation, hostile or otherwise, seems vanishingly remote- for reasons entirely unrelated to the probability of life on other planets. If interested in the mind-boggling barriers to such inter-stellar concourse, I recommend Lawrence Krauss' book, A Universe from Nothing, as a good place to start.

But the threats to us all, threats blind to the borders of nations, and deaf to the distinctions of ideology, are already here. They have no need to traverse the distance between stars.

The faults we must overcome for our own security lie not with exotic perils from distant stars, but with dangers evolving right here at home. The faults lie most particularly with ourselves. Ironically, Zika is named after a forest, and one of our great liabilities is the recurrent failure to see the forest through the trees. We react to each new pathogen, while doing little to anticipate the next.

We often fail as well to perceive and prioritize our common humanity. We rally to the defense of it when fighting the threats of science fiction fantasy, but miss the opportunity to do so in the face of real, clear, present, and inevitably recurrent danger.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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