Why Can’t We Talk About Prevention?

I have been sitting on the Antibiotic Utilization Committee Meeting in Glasgow now for more than a year. It took me a while to work out what was going on, firstly, because secondary care clinicians love using millions of abbreviations, and secondly, because it’s an incredibly detailed meeting with lots of data and information regarding many drugs I don’t ever use Eg. IV antibiotics and antibacterial, antifungal and antiviral drugs which are only ever prescribed in hospitals by specialists.

The use of these drugs is big business and it takes up a considerable amount of the drug budget each year. I have eventually worked out that the function of the committee is to monitor both the cost and quantity of antimicrobials being prescribed and compare these to other areas in Scotland and agreed national guidelines.

As you can expect there are seasonal fluctuations and the odd rogue prescriber that challenges the system. Just when you think the usage is stable, a national oversight group will change the guidelines and the prescribers will respond by doing more quality improvement activities and audits, and try to tighten every aspect of prescribing to ensure cost effectiveness and adherence to guidelines.

The group have been quite effective over the years in encouraging more evidence – based prescribing, curbing the use of antimicrobials and reducing harms through overprescribing such as Clostridium Difficule infections. However there has been one glaringly obvious angle that this group has never addressed in all the time I have been at the meetings – Prevention.

Prevention of infection has not been on the agenda once in the last year, despite each meeting lasting around 3 hours. Nobody has asked “how do we prevent people getting infections?” The only time this has been considered is in the case of C. Diff infections which are caused by us prescribing too many antibiotics. Even in the case of C. Diff prevention the only angle being considered is the reduction in antibiotic prescribing on the wards.

I have a problem with this approach because it tends to suggest a general hopelessness towards self- care and preventative health methods.

Western medicine does not encourage preventative health, instead it reacts to disease throwing drugs in its path and hoping it will resolve. Patients are treated the same, given the same drugs for the same disease and no consideration is made towards why each person got the disease in the first place.

If you take a simple infection like UTI, you may think there is no point in finding out why they got it, best just to give the 3 days of antibiotics and hope it goes away. What is the harm in this, its efficient and cheap and everyone can be taught a protocol for what to give and how long to give it for. However, the story did not begin with the development of UTI symptoms, it began before this and each person will have a different story, a different mechanism by which their infection came about. For example, a 4 year old child developing a UTI because of difficulty wiping her bum is different to the middle age woman who gets a UTI because of a combination of dysbiosis of her gut microbiome and intercourse moving the bacteria towards her urinary tract.

Other things complicate our stories Eg sleep deprivation lowering our immune function, emulsifiers in our diet creating weaponized bacteria and increasing gut wall permeability, lack of vitamin D – an essential player in our immune function, diets lacking in plants and high in carbohydrates and harmful fats driving inflammation in our bodies , sedentary lifestyles driving our inflammatory response , drugs and harmful substances which may weaken immune responses or alter our gut microbiome and finally stress which damages our immune function further. This list is exhausting to read but sadly most people in our society will experience some or all of these issues in life and will not realise the impact they have on their day- to- day health and ability to fight off infections naturally.

Indeed, most of us are so indoctrinated by modern medicine practices of prescribing a drug for every condition we have forgotten that our body is amazing. Its immune system is so highly advanced we still don’t understand it all. It fights off bacteria, viruses and fungi and destroys cancer cells every day without us having to do anything. We have become so complacent about our bodies ability to do these things that we have stopped respecting it. Surely if we respected our bodies more, we might start to allow ourselves more meaningful rest, stop and consider what substances we put into our body, make sure we keep ourselves fit and avoid stress.

We need to stay away from drugs unless we really need them and we should consider lifestyle- change as a first line approach for modern disease and avoid over-prescribing. We need to treat the patients who do not have infections before they get them. Without this change we will continue to go round in circles but with a growing population and a society that is becoming more and more unwell with chronic diseases and multiple infections, the cost and quantity of antimicrobials and other drugs will only increase. Modern medicine has lost it way, guidelines and protocols though useful have prevented us from seeing and considering other ways of doing things.

So, while my colleagues are following guidelines, I have quietly been encouraging lifestyle changes and self- care by my patients every day. I have noticed that many of my patients can self-treat their recurrent UTI’s and herpes infections, they can manage acne without antibiotics, they can treat their chronic diseases without drugs, lowering their blood pressure and weight with diet and exercise, reversing their diabetes and improving their mood without antidepressants. My practice is consistently one of the lowest prescribers of antibiotics.

So, why can’t we talk about prevention?