Biding the Pelting of this Pitiless Storm

Hubris –the extreme arrogance that was so offensive to the old Greek gods that they reacted with punishment and an exile from grace- is that what this is? I’m not sure anymore… It’s not, perhaps, so obvious as the vaulting ambitions of a Macbeth or the arrogance of a Caesar, nor even the overweening pride of an Oedipus in the Sophoclean plays, and yet… And yet, viewed from a distance, it’s hard not to notice the similarities that inhere in the attitude that End justifies Means, that intentions trump consequences, that methodology is the servant of results –however narrowly beneficent we define them. And it’s important that we not be so blinded by those touted benefits that we ignore other, perhaps less harmful routes, to achieve them.

And what, you may reasonably ask, prompted this jeremiad? It was a study reported in the New England Journal of Medicine (NEJM) on the addition of a second and possibly more powerful prophylactic antibiotic during non-elective Caesarian Sections to reduce post-operative infection rates: http://www.nejm.org/doi/full/10.1056/NEJMe1610010?query=gynecology-obstetrics -certainly a worthy aim, to be sure. Who could possibly take issue with that? Well, in this era of increasing antibiotic resistance, and the unfortunate dearth of replacement antibiotics in the wings, I think not only the study, but also the idea demands more than a cursory analysis. This is not to criticize the intent, so much as to explore alternative roads to the same destination.

Few would argue that antibiotics, when they are deemed necessary, should be used according to the infecting bacterial sensitivities if they are available –or considered expectations as to sensitivities if they are not. It’s why we can no longer use penicillin for everything –not all infections would respond. Surgical prophylaxis (where there is not yet an infection) is one of the few exceptions, and even there, the antibiotics are chosen in anticipation of the type of bacteria that might reasonably be expected in the surgical field (although there are some who believe that their effect is merely that of decreasing the total bacterial load in the area whether or not the expected ones have been targeted). But, nevertheless, we toy with resistance at our peril.

I’ve chosen to link the editorial rather than the study itself because of the insights it offers. The full-length study to which it refers can be accessed via a link in that editorial, however.

As I mentioned, the study by Tita and colleagues, in a randomized trial, attempted to reduce post-operative infections by adding another broad-spectrum antibiotic (Azithromycin) to the usual antibiotic (cefazolin) in non-elective Caesarian sections (i.e. there was some condition in mother or baby that required urgent delivery) where the current infection rate was 12% -and it worked! Compared to the usual group that just received the cefazolin alone, they dropped the infection rate to 6.1% -not zero, but at least an improvement. And, ‘Neonatal outcomes, which were tracked up to 3 months, were similar in the two trial groups.’

But on closer analysis, 73% of the population in the study was obese -and that, plus the fact that the Caesarians were unplanned, certainly added to their risk of infections. So far, so good.

But, as the editorialist wonders, could the fact that these women were obese have meant that the usual dose of cefazolin was inadequate: ‘[…] should the potential pharmacologic benefit of higher doses of cefazolin alone be evaluated further before the addition of a second agent?’

Another consideration leading to the study of adding azithromycin to the regimen, was that it may be useful for eliminating a potentially  infective organism in the vagina –ureaplasma– that cefazolin doesn’t touch. Unfortunately, there are no prospectively adequate data for the contention that the organism was even present in the studied women.

And finally, the azithromycin was more beneficial in those women whose incisions were closed with staples, and there seems to be evidence that staples, themselves, may increase the post-operative infection rate.

So why, you may ask, have I chosen to comment on this rather obscure study –especially since it seems to have demonstrated the benefits it expected? First of all, I think we have to be careful that we don’t lose sight of the forest as we wend our way through the undergrowth. There do seem to be other options that could be explored before the addition of yet another antibiotic –and indeed should be anyway, given the non-zero infection rate even with the addition of azithromycin. Such things as more ‘stringent adherence to infection-control protocols’, avoiding the use of staples in this high-risk population, or even re-calculating the dose of the standard prophylaxis (cefazolin) to account for differing patient weights before deciding to add the new antibiotic.

I don’t mean to be the new Cassandra, issuing thundering prophesies of doom that will not be heeded anyway, or aspersing well-intentioned attempts to improve our lot… And yet we must not forget that consequences follow actions, not precede them. To be fair, we do try our best to anticipate and thereby avoid, or at least minimize them, but history is riddled with examples of unintended outcomes. The road to disaster is paved with should’ves –only seen with clarity, after arrival.

It seems to me that, wherever possible, we should be exploring options that reduce the likelihood of incurring bacterial resistance. And the answer may not lie in the reliance on new antibiotics -new guns for our on-going war with the microscopic world. It’s a battle in which we cannot hope for more than a temporary truce while we search for peace. Without that, as the map makers of old were said to write on unexplored regions, Here be dragons.

 

Are We There Yet?

There are some things you just have to get right -or else. But, or else what..?  Continuing exposure, even to the most egregious injustices risks dulling the senses; eliciting not indignant shouts but shrugs, excuses not action. Accommodation.

There are benefits that accrue to adaptation, of course –if one lives next to a pulp mill, the objectionable odours soon fade into the background; if one lives in a dangerous neighbourhood, one discovers ways of staying out of danger; these are mechanisms for survival. We can grow accustomed to the most outrageous things, we can attempt to normalize the abnormal. And yet…

And yet that which is abnormal to one culture may be the norm in another. But here be dragons –as ancient cartographers used to say about unexplored territories on maps. One has to differentiate between cultural relativism –accepting that there are many ways of being in the world- and injustice or cruelty meted out in the pursuit of a majority-held social belief system. One that has perhaps been practiced by a population for uncounted generations –so long, even, that it is no longer considered aberrant. No longer noticed.

And the territory is heavily mined –to criticize it, or attempt a change, however laudable, can be seen by those affected as ill-informed at best, and intrusive at worst. Let’s face it, for some issues the dissent is over ideology. Political systems. America, for example, has a thing about spreading its own version of participatory democracy and can’t seem to understand the objections to its imposition –by force if necessary. Others, less convinced of the superiority of the American interpretation, resent the interference, attributing other more venal reasons for its meddling. And who is right? It evidently depends on where you live. Truth defines itself.

But some things do seem to transcend culture and are difficult to defend no matter what the historical cultural practices –torture, physical abuse, murder, to name but a few examples. Whether by outside example, domestic protests, or perhaps even token acquiescence to seem compliant, there is some progress in that regard. For example, I was pleased to see that ‘China has drafted its first national law against domestic violence.’ http://www.huffingtonpost.com/2014/11/26/china-domestic-violence_n_6225876.html The drafted legislation ‘creates a formal definition of domestic violence for the first time and streamlines the process of obtaining restraining orders.’ There are several parts of it that could be improved of course; still, it is a start. A recognition that there was a grievous injury in the body politic. A wound that was long overdue for surgery.

The recognition of defects such as domestic abuse, long tolerated in cultural folkways, is perhaps a natural progression as a society develops. But I worry that the legal protection that is put in place may occasionally overshoot its mark and end up as oppressive as the practice it replaces. It requires thoughtful consideration and sober second thought to prevent unintended injustice. Prejudicial enquiry. Discrimination. As my daughter used to keep asking any time she sat in the car: “Are we there yet, daddy?” “Pretty soon,” was the only answer that seemed to satisfy her -if only briefly. But in this case, soon is not at all satisfying.

In the case of domestic violence –sexual, or otherwise- investigation of the alleged abuse must balance the difficulty of the aggrieved partner in coming forward with the information –the danger to her both physically and emotionally, not to mention the social and legal stigma that might ensue- with the right of the accused to be fairly adjudicated and the evidence impartially considered. I recognize that in this type of situation, it is difficult to progress from a ‘He said, she said’ situation to a balanced appraisal of whatever information is available without seeming to impune the word of either party. And I also understand that, no matter the guilty party, reputations of both, and perhaps even standing and subsequent acceptance in the community, might be at stake. Merely acknowledging the need for a remedy does not necessarily create one.

Sexual harassment falls under a similar rubric, but it is a field even more heavily mined. There seems to be an encouraging awareness of the problem nowadays; women are speaking up about it but often only when it has become intolerable. Indeed even our Canadian parliamentarians are not without blemishes in this regard: http://www.cbc.ca/news/politics/harassment-allegations-against-2-liberal-mps-rest-with-secretive-committee-1.2825385

The issues this type of situation illustrates, are in themselves problematic however: http://www.cbc.ca/news/politics/harassment-on-parliament-hill-6-unanswered-questions-1.2826026 There seems to be no easy solution to the fact that it is important that both sides be heard –not condemned out of hand. Allegations are uncomfortable to submit, and often frought with disciplinary actions should they fall prey to power structures. All too often the victims are too frightened of losing their jobs, or of the publicity and possibility of public ridicule to come forward. Hence the appeal of anonymity, or mechanisms for keeping the accusations one step removed from them. Avoiding potentially damaging confrontations.

But while this offers protection for the victim that is unquestionably desirable if the harassment is to be stamped out, it unfairly (perhaps) predjudices the accused. Unless we accept the concept that a person is guilty until proven innocent, then it is incumbent upon whatever authorities are charged with processing the accusation to adopt an equitable appraisal of all the evidence. Hear both sides.

No matter the society, no matter the longstanding traditions, no matter the crime or the accusations, evidence should trump. It is all too easy to form opinions and act on insufficient information, whatever the ideology involved. It is all too easy to assign blame, especially in the field of personal relations.

But I don’t know… I guess in the end, I’m reminded of Claudio in Shakespeare’s Much Ado About Nothing:

Let every eye negotiate for itself

And trust no agent; for beauty is a witch

Against whose charms faith melteth in blood.”