The role of pharmacy in healthcare

Pharmacists are experts on the actions and uses of drugs, including their chemistry, their formulation into medicines and the ways in which they are used to manage diseases. The principal aim of the pharmacist is to use this expertise to improve patient care. Pharmacists are in close contact with patients and so have an important role both in assisting patients to make the best use of their prescribed medicines and in advising patients on the appropriate self-management of self-limiting and minor conditions. Increasingly this latter aspect includes OTC prescribing of effective and potent treatments. Pharmacists are also in close working relationships with other members of the healthcare team –doctors, nurses, dentists and others –where they are able to give advice on a wide range of issues surrounding the use of medicines.

Pharmacists are employed in many different areas of practice. These include the traditional ones of hospital and community practice as well as more recently introduced advisory roles at health authority/ health board level and working directly with general practitioners as part of the core, practice-based primary healthcare team. Additionally, pharmacists are employed in the pharmaceutical industry and in academia.

Members of the general public are most likely to meet pharmacists in high street pharmacies or on a hospital ward. However, pharmacists also visit residential homes (see Ch. 49), make visits to patients’own homes and are now involved in running chronic disease clinics in primary and secondary care. In addition, pharmacists will also be contributing to the care of patients through their dealings with other members of the healthcare team in the hospital and community setting.

Historically, pharmacists and general practitioners have a common ancestry as apothecaries. Apothecaries both dispensed medicines prescribed by physicians and recommended medicines for those members of the public unable to afford physicians’fees. As the two professions of pharmacy and general practice emerged this remit split so that pharmacists became primarily responsible for the technical, dispensing aspects of this role. With the advent of the NHS in the UK in 1948, and the philosophy of free medical care at the point of delivery, the advisory function of the pharmacist further decreased. As a result, pharmacists spent more of their time in the dispensing of medicines –and derived an increased proportion of their income from it. At the same time, radical changes in the nature of dispensing itself, as described in the following paragraphs, occurred.

In the early years, many prescriptions were for extemporaneously prepared medicines, either following standard ‘recipes’from formularies such as the British Pharmacopoeia (BP) or British Pharmaceutical Codex (BPC), or following individual recipes written by the prescriber (see Ch. 30). The situation was similar in hospital pharmacy, where most prescriptions were prepared on an individual basis. There was some small-scale manufacture of a range of commonly used items. In both situations, pharmacists required manipulative and time-consuming skills to produce the medicines. Thus a wide range of preparations was made, including liquids for internal and external use, ointments, creams, poultices, plasters, eye drops and ointments, injections and solid dosage forms such as pills, capsules and moulded tablets (see Chs 32–39). Scientific advances have greatly increased the effectiveness of drugs but have also rendered them more complex, potentially more toxic and requiring more sophisticated use than their predecessors. The pharmaceutical industry developed in tandem with these drug developments, contributing to further scientific advances and producing manufactured medical products. This had a number of advantages. For one thing, there was an increased reliability in the product, which could be subjected to suitable quality assessment and assurance. This led to improved formulations, modifications to drug availability and increased use of tablets which have a greater convenience for the patient. Some doctors did not agree with the loss of flexibility in prescribing which resulted from having to use predetermined doses and combinations of materials. From the pharmacist’s point of view there was a reduction in the time spent in the routine extemporaneous production of medicines, which many saw as an advantage. Others saw it as a reduction in the mystique associated with the professional role of the pharmacist. There was also an erosion of the technical skill base of the pharmacist. A look through copies of the BPC in the 1950s, 1960s and 1970s will show the reduction in the number and diversity of formulations included in the Formulary section. That section has been omitted from the most recent editions. However, some extemporaneous dispensing is still required and pharmacists remain the only professionals trained in these skills.

The changing patterns of work of the pharmacist, in community pharmacy in particular, led to an uncertainty about the future role of the pharmacist and a general consensus that pharmacists were no longer being utilized to their full potential. If the pharmacist was not required to compound medicines or to give general advice on diseases, what was the pharmacist to do?

The need to review the future for pharmacy was first formally recognized in 1979 in a report on the NHS which had the remit to consider the best use and management of its financial and manpower resources. This was followed by a succession of key reports and papers, which repeatedly identified the need to exploit the pharmacist’s expertise and knowledge to better effect. Key among these reports was the Nuffield Report of 1986. This report, which included nearly 100 recommendations, led the way to many new initiatives, both by the profession and by the government, and laid the foundation for the recent developments in the practice of pharmacy, which are reflected in this book.

Radical change, as recommended in the Nuffield Report, does not necessarily happen quickly, particularly when regulations and statute are involved. In the 28 years since Nuffield was published, there have been several different agendas which have come together and between them facilitated the paradigm shift for pharmacy envisaged in the Nuffield Report. These agendas will be briefly described below. They have finally resulted in extensive professional change, articulated in the definitive statements about the role of pharmacy in the NHS plans for pharmacy in England (2000), Scotland (2001) and Wales (2002) and the subsequent new contractual frameworks for community pharmacy. In addition, other regulatory changes have occurred as part of government policy to increase convenient public access to a wider range of medicines on the NHS (see Ch. 4). These changes reflect general societal trends to deregulate the professions while having in place a framework to ensure safe practice and a recognition that the public are increasingly well informed through widespread access to the internet. For pharmacy, therefore, two routes for the supply of prescription only medicines (POM) have opened up. Until recently, POM medicines were only available on the prescription of a doctor or dentist, but as a result of the Crown Review in 1999, two significant changes emerged.

First, patient group directions (PGDs) were introduced in 2000. A PGD is a written direction for the supply, or supply and administration, of a POM to persons generally by named groups of professionals. So, for example, under a PGD, community pharmacists could supply a specific POM antibiotic to people with a confirmed diagnostic infection, e.g. azithromycin for Chlamydia.

Second, prescribing rights for pharmacists, alongside nurses and some other healthcare professionals, have been introduced, initially as supplementary prescribers and more recently, as independent prescribers.

The council of the Royal Pharmaceutical Society of Great Britain (RPSGB) decided that it was necessary to allow all members to contribute to a radical appraisal of the profession, what it should be doing and how to achieve it. The ‘Pharmacy in a New Age’consultation was launched in October 1995, with an invitation to all members to contribute their views to the council. These were combined into a subsequent document produced by the council in September 1996 called Pharmacy in a New Age: The New Horizon. This indicated that there was overwhelming agreement from pharmacists that the profession could not stand still.

The main output of this professional review was a commitment to take forward a more proactive, patient-centred clinical role for pharmacy using pharmacists’ skills and knowledge to best effect.

Why Asians are more prone to Type 2 diabetes than Westerners

Thirty-four year-old Alan Phua is what you might describe as a typical male Chinese man. He exercises for three to five times a week in a country that places a high emphasis on healthy lifestyles. He also carefully observes what he eats and is strict about his diet.

Alan lives in Singapore. In addition to military service for the duration of two and a half years when they turn eighteen, citizens have annual reservist training for two weeks until they turn forty. Failing to meet targets for physical exercises such as chin ups, standing broad jumps, sit ups, shuttle runs and a 1.5 mile run means remedial physical training every few months until these standards are meet. But not all is negative though. Meeting or exceeding these targets is rewarded by financial incentives. In other words, living in Singapore as a male means there is a strong push to keep fit and maintain it.

The reasons for this are very clear. Singapore is a small country surrounded by two large neighbours in Malaysia and Indonesia. Its population of five million citizens means that like Israel, it has to rely on a citizen reservist force should the threat of war ever loom. While most of the citizens there seem of the mindset that military war would never break out, as the country is so small that any military action would damage the infrastructure and paralyse it; furthermore, the military is only a deterrent force, the readiness to military action gives leverage in negotiations between nation. For example, if the countries disagree over the supply of water that Malaysia gives Singapore to refine, and the discussions escalate towards a military standoff, having a reservist army puts the country in a better negotiating position. But while many may claim that a war is hypothetical, there is a simpler reason for maintaining fitness. A fitter population means less stress on the healthcare system. Singapore is the sustainable healthcare system that many countries are seeking to adopt.

Like many others in Singapore, Alan’s body does not produce enough insulin. This, as a result, causes the accumulation of sugar in the bloodstream. The lack of insulin leads to other health issues, such as general fatigue, infections, or other effects such as the failure of wounds to heal. However, all is not lost. Eating properly and having a good level of exercise can prevent the blood glucose level from rising and developing into diabetes.

Local researchers from the country’s National University Hospital (NUH), working together with Janssen Pharmaceuticals, have discovered that the reason why Asians are moresusceptible than Westerners to developing Type 2 diabetes is the inability of their bodies to produce high enough levels of insulin.

Even though the finding was based only on a small sample size of 140 mostly Chinese participants, the data, if expanded and refined, will point the way and help patients with diabetes to manage it better; not just for local patients but also within the region. Doctors believe that better dietary advice and a better selection of drugs would help patients to treat diabetes. The preliminary findings are part of the country’s largest diabetes study launched last year. The five-year ongoing study has recruited around 1,300 participants, and aims to eventually nearly double that.

The researchers did however notice the ethnicity of the results was fairly restricted and more participants from a wider racial profile will be needed for the results to be applied to the general population.

Currently, the statistics show that one in three Singaporeans has a risk of developing diabetes. Currently, one out of every fourteen Singaporeans are diabetic. Type 2 diabetes comes about because insufficient insulin is produced by the pancreas, or because the body has insulin resistance.

A previous study that 8 per cent of Chinese people with a Body Mass Index (BMI) of 23 have diabetes. A BMI of 23 is within the normal weight range for Caucasians, and the rate of diabetes development within Chinese people is four times more than their European counterparts. The researchers claimed that it highlighted the importance of avoiding too much high-glucose food such as those rich in simple carbohydrates which include white rice and sugar.

The findings could also lay the foundation for efforts to test whether therapies that target insulin secretion and the ability to make more insulin could be more effective in the local population, and lead to customised diabetes treatment.

What bearing does this have on us, and what action can we take? A good start would be to avoid eating high glucose food such as rice too often and managing our diet. Also try adopting a more active lifestyle!

What your breakfast reveals about media companies

Wordsmiths would tell you that the origins of the word “breakfast” lie in the words “break” and “fast”. Then again, you wouldn’t actually need an expert to tell you the combined word comes from its intention – to end the fasting period. What fast? Presumably in Roman days the fast represented the period from after sunset to sunrise, where people had to endure going without food in the cold of night, at a time when the thinking was “Eat as much as you can during the day, while you can”. The line of thinking about what to eat for breakfast certainly does vary from place to place. Some believe that after a period of doing without food – okay, so a few hours every evening now after a “Just Eat” gorge of Indian takeaway washed down with bottles of Kingfisher can hardly be called a fast anymore –  the body has to stock up on its resources. Enter the full English breakfast; sausages, bacon, eggs, tomatoes, beans (mustn’t forget your greens), black pudding – everything you wanted to eat during the day, presented to you literally on a plate, in case you miss the opportunity to eat later on. In contrast, there are others of the thinking that after an overnight period of doing without, the body cannot be forced into what is a gorge. Just as someone who is parched and dehydrated has to resist the natural urge to guzzle down water when presented with it, breakfast, some think, is only a primer for a heavy lunch. Hence the idea of a light continental croissant, a little way of appeasing the hungry body but regulating the intake of food so the body is not lulled into a yo-yo pattern of starvation and gorging that is more typical of eating disorders.

Makes sense? Both points of view actually do, despite the conflicts about whether or not to eat heavy first thing in the morning. But to further complicate the issue, a third group believes that since your body, when at rest, will require resources to draw on when you are asleep, then it makes perfect sense to load up with a heavy meal as the last meal of the day. Start light, finish heavy. Viewed in the context, it makes sense too.

If there is any one consistent factor about diet, it is probably that the debate, ideas and media reports will continue into the future, and ideas will come and go and come back again. The fad for various diets has sold books and filled magazine columns and given the media lots to write about, which is great for the industry because media is not a sector that relies on bringing to you information that is necessarily correct, it is a sector that relies on attracting readership and human traffic in order to build up a reader base which it leverages to companies to sell advertising. Advertising is what drives media, not the exposition or exploration of facts. Hence media companies will present information that they feel is of interest and will hook in readers. It doesn’t necessarily have to be substantiated, as long as there is a fellow source to mention, as if the validation of facts had been corroborated by them.

Where do research scientists fit in this grand scheme of things? There are various kinds of research scientists, ones that truly explore the world in order to further it, and others who conduct investigation in order that it may be latched on to by the media in reports. Ultimately it comes down to who is funding the work. Funded by a company such as Cancer Research? The investigative research conducted by such research scientists is likely to be subject to stringer validation. Funded by a pharmaceutical company? The data obtained by such research needs to be handled carefully in order that the outcomes are not flawed or biased towards any products the company is producing.

In other words, if a pharmaceutical company is working on producing a medical product that is, for example, has seaweed as an active ingredient, then the research must not be conducted in a way that only shows the positive benefits of seaweed; research that only gives supposed scientific validation to a pre-determined result.

Bias is all too easy to spot when the links are direct, when a pharmaceutical company employs scientists. But what happens when the grand paymaster is the media company?

Hang on, I hear you say. Why would a media company, perhaps a newspaper, employ a group of scientists? And how could they get away with it?

The end product for a pharmaceutical company is a medical one. The end product for a newspaper is news, and the research scientists are there to provide it.

The group of scientists don’t necessarily need to be under permanent employ, just occasional contract work when there are lull periods in the news. And the work that they do is not necessarily related to what is in the article that is published anyway. Tenuous links are exploited to maximise the draw of a headline.

This is how it works:

A shark is a fish. A whale is a fish. Your newspaper reports that there is the possibility that sharks could become whales.

And that’s it.

A media company – newspaper, magazine, channel, web agency – can hire research scientists to lend credibility to semi-extravagant claims.

As long as there is another attributable source, or somewhere to dismiss the evidence – easily done by mentioning “It is generally accepted that …” or “Common convention holds that …” before launching into the juicy bit – the bit that spins things out, through a long process by which the receiver, either reader or viewer, has hopefully forgotten what the gist of the argument was in the first place – everything can passed off. In fact, it is a psychological trick – the receiver keeps following in the hope of being able mentally ordering the great influx of information.

Ever watched a BBC drama series? After six episodes, numerous disjointed flashbacks, the final  episode always seems a bit of a letdown because you realise everything was obvious and the in-betweens were just filler bits to spin things out.

I digress. But returning to the point, media companies can hire research scientists on an occasional basis. Some may even do so, and have a scientist for full time hire as a generator of scientific news.

A direct link between a media agency and a research scientist may sound implausible. But think of the UK’s Channel 4 programme, Embarrassing Bodies, where a team of four doctors go around examining people, dispensing advice, running health experiments in a format of an hour-long slot punctuated by two minutes of advertisements for every thirteen minutes of the programme.

If the media company does not want its links to be so obvious, it can dilute them progressively through the form of intermediary companies.

For example, ABC newspaper hires DEF company to manage its search engine optimisation campaign. DEF hires GHI creative media, who hire  JKL, a freelance journalist who knows Dr MNO, who conducts research for hire. Eventually MNO’s “research” ends up in the ABC newspaper. If it proves to be highly controversial or toxic to some extent, ABC’s links to MNO are very, very easy to disavow.

So when the media recently reported that scientists say skipping the morning meal could be linked to poorer cardiovascular health, should we pay any heed to it?

The research findings revealed that, compared with those who had an energy-dense breakfast, those who missed the meal had a greater extent of the early stages of atherosclerosis – a buildup of fatty material inside the arteries.

But the link been skipping breakfast and cardiovascular health is tenuous at best, as the articles themselves admit.

“People who skip breakfast, not only do they eat late and in an odd fashion, but [they also] have a poor lifestyle,” said Valentin Fuster, co-author of the research and director of Mount Sinai Heart in New York and the Madrid-based cardiovascular research institute, the CNIC.

So a poorer lifestyle gives negative impact to your health. A poorer lifestyle causes you to miss breakfast. Sharks do become whales.

This supposed link between skipping breakfast and cardiovascular health was published in the Journal of the American College of Cardiology, and the research had partly been funded by the Spanish bank Santander. The health and diets of 4,052 middle-aged bank workers, both men and women, with no previous history of cardiovascular disease were compared.

You can bet that on another day where news is slow, someone will roll out an “Eating breakfast on the move harms your health” headline. Nothing to do with the way you move and eat, it is simply because you have a stressful lifestyle that impacts on your health which forces you to eat on the go. But it was a link and headline, a “sell” or bait that drew you in to either purchase a newspaper or magazine, watch a programme, or spend some dwell time on a site.

And that’s how media works.

Revising Traditional Antibiotic Advice

What do you do when you have a cold and feel under the weather? Perhaps you decide to tough it out, and head to work as usual. You grin and bear it, because as far as you are concerned, it’s just a common cold and you can’t do anything about it.

But suppose you don’t get any better after a week, when you expected that the cold would have already run its course. You decide to stay at home to rest, and after a further two days when no improvement is seen, you go to visit the doctor.

The doctor’s advice? A course of antibiotics. Two tablets three times a day after meals, and by the way, keep finishing the course even when you feel better.

This is the advice that has been dispensed through decades to patients. Finish the whole prescription of antibiotics. And as patients, we put our trust in doctors so whatever they said went. Who were we to argue with seven years of medical training?

But what would you say if this medical advice turned out to be incorrect? I know what I’d think – firstly the sceptic in me would say medical advice is fickle and flows with what is fashionable at the time. At times, medicine seems also subservient to politics and economy. Remember the case with red wine? When the economy was flagging, a glass of red wine was said to be good for you. Yet when the NHS was under strain this so-called health benefit was reversed.

In this day and age it is also fashionable for everyone to carve a niche for themselves, and for many the way to do so is to turn traditional advice upside down on its head and revise or reformat existing information. And so, with these in mind, it is unsurprising that we learn of yet another study that claims the rule that patients must finish antibiotics course is wrong.

The new slant on the old problem is that patients should stop taking the prescribed medication when they feel better rather than as what doctors previously used to recommend.

The new panel of experts suggest that  the long embedded rule is incorrect, because continually taking medication after we have felt better only lowers the body’s resistance in the long run. They argue that if the body already feels better, giving it medication it does not need has counter-productive effects.

This differs with the advice that doctors have traditionally recommended, which is based on the idea that bacteria remains in our bodies even though we feel better and these bacteria may develop adaptation to antibiotics if they are not fully killed off. In other words, if you have not fully killed off the bacteria, it develops tolerance and immunity to the drug which partially fended it off, and ultimately the antibiotics’ effectiveness is negated.

Imagine two medieval armies: Trojans and Greeks. One day the Trojans manage to get inside the Greek city walls and wreak havoc (according to the Greeks anyway) with their torches, spears and swords. But the Greeks have a special weapon, say for arguments’ sake, an M16 with a laser sight. If the Greeks completely defeat the Trojans, the effectiveness of their weapon is guaranteed against successive waves of Trojan attacks. But if the Greek army stops to celebrate the moment the city battle swings in their favour, retreating Trojans may bring back information about the weapon, and how it works, and plan successive attacks that limit the effectiveness of the weapon or destroy it completely.

Martin Llewelyn, professor in infectious diseases at Brighton and Sussex medical school have called for a re-examination of the traditional advice. In an analysis in the British Medical Journal, they say “the idea that stopping antibiotic treatment early encourages antibiotic resistance is not supported by evidence, while taking antibiotics for longer than necessary increases the risk of resistance”.

In other words, stop taking the medicine the moment you feel better.
In the past, the theory supporting the completion of a course of antibiotics has been that too short a course would allow the bacteria causing  disease to mutate and become resistant to the drug.

For certain diseases, bacteria can clearly become resistant if the drugs are not taken for long enough to completely eradicate them. One such example of this is tuberculosis.

But a large majority of the bacteria that cause illnesses are found in the environment around us and have no impact until the bacteria gets into the bloodstream or the gut. The case putting forward a cessation in medication once the patient’s health improves is that the longer the bacterial exposure to antibiotics within the body, the higher the chance of developed resistance.

The hypothesis put forth by Professor Llewelyn has not been without its backers.

Peter Openshaw, president of the British Society for Immunology, said he had always considered the notion  that stopping antibiotic treatment early would make organisms more drug-resistant rather “illogical”.

He supported the idea of a more sparing use of antibiotics because the evidence of a link between long-term complete use and benefit was tenuous.

He dismissed claims that not finishing a course of antibiotics would lead to bacteria gaining antibiotic resistance but thought the reverse would be more true. “Far from being irresponsible, shortening the duration of a course of antibiotics might make antibiotic resistance less likely.”

A great British authority, Prof Harold Lambert had made the suggestion as far back as in 1999 in a Lancet article entitled “Don’t keep taking the tablets”. Even though the idea had been broached then, it had not been taken seriously and with hindsight it is surprising that nearly two decades later the medical world has not investigated the alternatives fully and that the optimum duration of antibiotics courses or doses in many conditions remains an investigated fast.

Jodi Lindsay, a professor of microbial pathogenesis at St George’s, University of London, stated that the new research by Professor Llewellyn was good in principle, and that the previous advice to complete a course of antibiotics may have been based on a fear of under-treatment. But nevertheless she cautioned against an over-reaction towards the results of the findings. “The evidence for shorter courses of antibiotics being equal to longer courses, in terms of cure or outcome, is generally good, although more studies would help and there are a few exceptions when longer courses are better – for example, TB.”

To complicate matters, the ideal length of a course of antibiotics varies in individuals depending on what antibiotics they have taken in the past. Hospitalised patients can be tested to find out when the drugs can be stopped. Outside of a hospital setting, this testing is not feasible.

The World Health Organisation advice is still based on the pre-existing guidelines and has not changed.

The Royal College of GPs, however, expressed caution over the findings. “Recommended courses of antibiotics are not random,” said its chair, Prof Helen Stokes-Lampard. She further elaborated that antibiotic treatment courses were already being customised according to individual conditions and if patients took it upon themselves to adjust the prescribed periods, stopping when they felt better, it would be dangerous because a slight turn in outlook did not necessarily demonstrate the complete eradication of the disease. Professor Stokes-Lampard also stressed that it was important for patients to have clear guidelines to adhere to and any adjustment using feel as an indicator might be confusing.

The National Institute for Health and Care Excellence is currently developing guidance for managing common infections, which will look at all available evidence on appropriate prescribing of antibiotics.

The cynics among us might ask, has such a review on current guidelines been made with the objective to cut the cost of medical care? It is well known the health budget is ever dwindling, and one cannot help but feel that the review on existing guidelines of antibiotics has been made with an objective to save on the cost of medicine rather than put patient health first.

The health service is currently riding the trend of developing sustainability in infrastructure and treatment, and this revision of traditional guidelines may seem to be a reframing of the evidence to suit a pre-determined outlook.

Let us return to the example of Greeks and Trojans. If the battle is raging within the Greek city walls and the tide turns against the Trojans, should the Greeks fire their ammunition at the retreating Trojans until they all fall to the ground? Ammunition in the form of gunpowder and metal casings cost money and if the ammunition could be used sparingly, then there is more money to funnel towards other  daily activities like farming and livestock. The question we are being asked to address is the equivalent of this hypothetical situation: Should the Greeks keep firing their weapons, until all the Trojans fall before they manage to retreat and leave the Greek city walls, or should the Greeks try to save the cost of a few rounds of ammunition if they are certain the Trojans are so heavily wounded they would never survive the escape and make it to their own city walls to compromise the information they know about the secret weapon?

You may decide, as I did, that the cost of a few extra rounds of ammunition outweighs all the mental confusion of wondering “what if …?” for the next few months. “What if I didn’t take the medication long enough? What if the bacteria has mutated?”

You can see why it is easier that when it comes to health, be cautious, don’t customise. Don’t experiment on the one life you’ve got!

What antibiotics in agriculture are really about

There is widespread concern over the use of antibiotics in the agricultural world and what is wider bearings are. The general consensus is that the use of antibiotics in agriculture needs to be minimised dramatically by farmers, as there are fears that drug-resistant bacteria could pass up the food chain through consumption and environmental contamination.

The concerns take on many forms. Firstly, just as humans can develop resistance to medicines after prolonged use, there is the concern that long-term antibiotic use in agricultural settings may create antibiotic resistance in the animals and crops which receive these antibiotics. Secondly, even if these crops and animals themselves do not develop resistance to antibodies themselves, the prolonged consumption of the vegetables or meat from these farm animals could breed resistance in humans who consume them. There may also be other side effects we are as yet unaware of.

Antimicrobial drugs, which include antibiotics, antifungal and antiparasitical drugs, are commonly used in farming. They are used to prevent damage to crops, kill parasites, as well as keep livestock healthy. The long term aim of antimicrobial drugs in the context of farming is to maximise crop production and livestock farming. A field of crops lost to infestation is months of work for nothing. A farmer with a field of cows suffering from disease has lost not just capital but production possibilities as well. As with the case of mad-cow disease in the 1990s, farmers who had their cows put down not only lost the money they had invested in buying and breeding these cows, but also on the sale of milk and beef.

And in many cases, the losses from a brief period of crop infestation or animal disease could significantly affect a farmer’s income, or make such a dent in their livelihood that it either forces them to take on additional debt to cover the losses, or be so insurmountable that it forces them out of business.

There might be those that argue against the use of antibiotics but the truth is that they are necessary. They are one form of insurance for a sector that has to combat various problems, including the uncertainties of weather. When, for example, your crops – your livelihood – are subject to the whims of weather, infestation, and perhaps human vandalism and theft, you have to take steps to minimise risks on all fronts. You cannot simply just leave things to chance and hope for divine favour or faith – that would merely be masking a lack of responsibility.

Pests and viruses do not restrict their infestation to selected fields. Left unchecked, they would merely spread from unprotected fields and livestock, and then infect further unprotected areas. Antibiotics are medical city walls that keep away marauding invaders, and prevent them from invading territories and conscripting the local population into their armies to do further damage.

Resistance to the antibiotics, antifungal and antiparasitical drugs used in agriculture is collectively known as antimicrobial resistance (AMR).

An independent body chaired by the British economist Jim O’Neill looked specifically at antibiotic use in the environment and agriculture. Among other things, this body examined the ways in which regulation and financial measures such as taxation and subsidies could play in reducing the risks associated with the agricultural use of antimicrobials and environmental contamination.

The data from the report suggests the amount of antimicrobials used in food production internationally is at least the same as that in humans, and in some places is higher. For example, in the US more than 70% of antibiotics that are medically important for humans are used in animals.

What does that all mean? It means that drugs normally for humans are already used in animals. If human beings consume the meat of the animals over prolonged periods, their bodies can develop tolerance to the antibiotics because they were used in the animals. If human beings later have a need for these antibodies, in the medicines for humans, these forms of medication will have little or no effect. And as we have seen before, ineffective long term medication may only create addiction to drugs and pain relief medication.

The report included peer-reviewed research articles in which 72% of the 139 articles found evidence of a link between antibiotic consumption in animals and resistance in humans. There is enough impetus for policy makers to argue for a global reduction of antibiotics in food production to a more appropriate level.

But while the evidence suggests that we should reduce the usage of these antibiotics, antimicrobial usage is unfortunately likely to rise because of the economic growth and for increasing wealth and food consumption in the emerging world.

A considerable amount of antibiotics are used in healthy animals to prevent infection or speed up their growth. This is particularly the case in intensive farming, where animals are kept in confined conditions. An infection in these confined spaces could easily spread between organisms. Further to this, some animals receive antibiotics so that natural limiters to size are killed off in order that their growth is accelerated. If you sell meat by weight, it makes sense that you try to produce as big as animal as you can so that you can maximise your profits.

The report mainly highlighted three main risks that had connections with the high levels of antimicrobial use in food production. There was the concern that drug-resistant strains could be transmitted through direct contact between humans, particularly in the case of farmers, and animals on their farm. Secondly, the transmission of the drug-resistant strains could also result due to the contact during the preparation of the meat, or the consumption of it. Thirdly, the excrement of the animals might contain the drug-resistant strains and the antimicrobials and therefore pass into the environment.

There was also concern raised about the possibility of contaminating the natural environment. For example, if factories that manufacture these antimicrobials do not dispose of by-products properly, these may pollute the natural environment such as water sources. Already we have seen that fish near waste-treatment plants, which treated urine tinged with chemicals from birth control pills, developed abnormal characteristics and behaviour.

The review made three key recommendations for global action to reduce the risks described. The first was that there should be a global target for the minimisation of antibiotic use in food production to a recognised and acceptable level in livestock and fish. There were also recommendations that restrictions be placed on the use of antibiotics in the animals that are heavily consumed by humans.

Currently there are no guidelines surrounding the disposal of antimicrobial manufacturing waste into the environment and the report urged the quick establishment of these in order that pollution of the environment could be minimised and the disposal of by-products and active ingredients be regulated.

The report also urged for more monitoring on these problematic areas in concordance with agreed global targets, because legislation without means of enforcement is useless.

Is it possible that the production of antimicrobials can be limited? One cannot help but be cynical. As long as we inhabit a world where sales drive rewards, it is inconceivable that farmers would slow down their production on their own initiative. We would definitely need legislation and some form of method to ensure compliance.

But what form of legislation should we have? Should we focus on imposing penalties for non-compliance or incentives to encourage the reduced use of antimicrobials?

Some may argue that the latter is more effective in this case. If farmers are offered financial subsidies so that they receive more money for the price of meat, for example, they would be more inclined to reduce the usage of antimicrobials. But how would these be monitored? Could the meat for sale could be tested to ensure the density of antimicrobials falls under established guidelines, for example, so that if the farrmer has been relying on the use of antibiotics to increase the size of livestock, he is latterly being recompensed for the reduction in size arising from the reduction of the antibiotics?

Unfortunately the difficulty is in reconciling both the need as well as the established economic system for growth in one hand, with the sustainability factor in the other. How is farm produce sold? When you buy a bag of salad, a cut of meat, or a bottle of milk, all this is sold by weight or volume. You may buy eggs in carton of six, but they are also graded by size and weight. For the direct manufacturer – the farmer – size, volume and growth are what bring about greater profits – although these profits may barely be just above the threshold for subsistence. And after making allowances for damage due to weather, theft, low market demand and all other variables that threaten an already low-profit industry, asking a farmer to reduce the use of antimicrobials is akin to asking him not to take measures to protect his livelihood. If the use of antimicrobials bothers you, then you have to compensate the farmer not to use them, by being willing to pay higher prices for farm products.

Why do organic or free range eggs cost twice the price for half the size? Aha!

While antimicrobials are also used on free range produce, and the case of organic farming is not entirely relevant here, the same issue is being highlighted here. You are paying more for the process than the product, and in doing so the extra payment that you make is towards the farmers for farming practices you are seeking to promote.

A farmer can get more produce by rearing battery hens, but if you are concerned over animal welfare, you pay extra per animal for the farmer to rear it with more space and hence more welfare for the animal. Your free range chicken costs more not because it is bigger, or necessarily healthier, but because it has been afforded more space, which you consider to be ethical. Farmers may switch to organic farming if there is enough demand for this, and for some this may even be more favourable, because having to produce fewer hens, but fetching the same price as battery hens, may, in the grand scheme of things, be seen by the farmer as a more favourable solution.

In trying to promote less use of antimicrobials, we have to make up the farmer’s perceived loss of earnings. So it is not incorrect to say that if we are concerned about the use of antimicrobials in agriculture, we have to pay more for our farm produce. Are you prepared to do that? For families with high disposable income, the increase may only represent a small additional fraction. But for families on smaller incomes, the increase may be too steep to be feasible. In other words, while the need for a reduction in agricultural antibiotics is recognised, in practical terms it may only remain an aspirational ideal except to those who can afford it.

Can be people be convinced – even if the cost is high – that in the long term it is better for human health? If the continued use of antimicrobials means that human medication in the future may become less effective as our resistance is tempered, should we, despite our reservations about the cost – make the leap towards maintaining a sustainable future? And if low-income families cannot afford to pay more in the cost of their weekly shop to get less, ridiculous as it might sound – should higher income earners step in to fill the shortfall?

It is strange how the wider discussion about the use of antimicrobials in society leads to a discussion about income distribution and political sensitivities.

What has arisen in the course of that evaluation, however, is the fact that expecting citizens alone to fully contribute towards the production shortfall arising from a reduced use of antimicrobials by paying more for their farm produce is not going to work. While some can afford to, many cannot, and those that can may not necessarily want to pay for those that cannot. There are also other measures to reduce the use of anti-microbials.

Governments could also introduce legislation to prevent environmental contamination through antimicrobial products and by-products, and harsh penalties for doing so. At the moment there are no rules in place, it is of increasing concern that such legislation is developed quickly.

Governments could also offer tax subsidies and support for farmers who continue to reduce antimicrobials usage. These could be introduced at the end of the first year, when farmers need most support at the initial stages of conversion, then at thirty months, and at further longer-spaced periods. Subsidies or incentives could an arithmetic progression at the end of one year, two-and-a-half years, four-and-a-half years, seven years and so on, so there is continued incentive to maintain reduced antimicrobial usage.

The only problem is, where would the money for these subsidies come from? If the government receives less tax from farm produce transactions because less has been sold, and it has also received less from antimicrobial companies in the form of tax, because it has made them limit their production, where will it make up the shortfall? Through an environment tax on its citizens?

Therein lies the problem.

The conundrum is this: the threat of antibiotic resistance in the future means we have to lower the level of antimicrobials we currently use. Yet if we do so, we are looking at reduced economic output. And as long as we have an economic system that is reliant on growth and increased production, asking to slow down production is economic suicide.

You may ask: “What about if we have a re-evaluation of an economic system, and create one that is based on sustainability?”

I am sorry to say it but that is wishful, idealistic thinking.

The problem with switching to a sustainable-based economy can be described as such.

Imagine there is a children’s party. At this party there is a table with a gigantic bowl of sweets. The children who are first to arrive eagerly stuff their faces and pockets with sweets, and as the party progresses, the bowl gradually looks emptier and emptier. The parents present chastise their kids if they continue to head for the sweet bowl, remonstrating with them to leave some for the kids who have not yet arrived from the party. Some of these children, perhaps the older ones, might reduce their trips to the bowl and the number of sweets they take. But some children will continue to plunder the bowl of its sweets before it all runs out and stuff their faces, recognising the sweets are a dwindling resource and if they want to eat them they’d best take as many as they can. And a third group, while recognising the sweets will soon run out, are equally keen to get hold of as many as they can, not to eat the sweets, but because they realise that when one of the latecomers arrives and find there are no sweets left, their parents may offer them incentives to trade to appease the desperate child. “Charlie didn’t get many sweets because he was late. If you let Charlie have two of the sweets you already have, I’ll buy you an ice-cream later.” This third group recognises not just the impending scarcity, but contribute to it by stockpiling their own resources to use for later leverage. And they may even make the loudest noises about how everyone should stop taking sweets, only so that they can make the biggest grabs when no one is looking.

Who are the losers in this situation? The obvious ones are the one who arrived late at the party. But the not so obvious losers are the ones from the first group, who amended their behaviour to ensure that there were still sweets left for the later groups to come. In being principled, holding on to ideals, they became lesser off materially, and the only consolation was the knowledge they had made the effort to leave some sweets for the late group – whether or not the latecomers actually got any or not is another question. The sweets ran out eventually.

The problem with thinking about sustainable economic measures is that the first to make an attempt to switch on ethical or aspirational grounds will be among the ones to lose out, because subsequent groups will still make a grab for whatever is left. Some will make a grab to get as much of the remaining resource, while others will make a grab so that when there is scarcity – and scarcity drives up prices – they have plenty of the resource to benefit. So while everyone is making the right noises about economic sustainability, everyone is just holding back for someone to make the first move.

So this is what antibiotics in agriculture really tells you: Too much can create problems later due to antibiotic resistance and improper disposal. We need to cut down on the use of antimicrobials. But reduced antimicrobials means reduced output, and we must be prepared to pay higher prices for less produce to compensate the farmer for that to work, in order that they may earn a living. The government can introduce penalties to govern the disposal of antimicrobial-related products to limit the damage on the environment alongside incentives to limit the use of antimicrobials. But it will have problems funding the incentives. Because what it is proposing is economic slowdown, in order to have an economy at all in later generations – but the current generations are too concerned with their own interests and survival, and stealthily making a grab for the remnants after the first few leave the economic arena.

Red wine – the media’s Wonderdrink

If there is anything to be said about the British media, it is that it seems intent to make a superhero or villain out of the common everyday foods we encounter. Every now and again we are presented with small-scale research on food or drink that promises either a miracle cure or a dangerous red flag. One assumption peddled to us is by continuing to consume the food, we will either gain added health benefit without too much effort. Miracle cure just by eating! The counter to this is the article written to warn against continued consumption. Danger food – consume carefully! You are either a superhero, or a villain in the world of miracle foods.

It is safe to assume that the purpose of these articles is ultimately to hook the reader into buying the newspaper to examine the article further. And if it appears on an online version instead, you can be sure that the intention is to keep the reader glued to the page while paid-for advertising revenue flashes on the side panels. To state it cynically, the purpose of these articles is for sales. It might be long before certain foods such as milk might purportedly be the cure to cancer.

We need not spend too much time judging how effective these media reports are. If you are looking to a newspaper as a reference for health advice, you might as well ask about ballet lessons from the petrol station.

One of the poster children for miracle foods is red wine. Depending on what you’ve read, red wine can:

  • Boost immunity
  • Prevent tooth decay
  • Save your eyesight
  • Be good for the heart

But it won’t help you in the fight against diabetes, or help you lose weight. Was worth considering, though.

One of the latest research into red wine studied if, yes, it could find the ageing process. A US study suggested resveratrol, a substance found in the skin of red grapes, may help keep our muscles and nerves healthy as we get older.

Researchers gave mice food containing resveratrol for a year, then compared the muscle and nerve cells of those mice to cells from mice the same age who’d had a normal diet. In the mice who’d had the resveratrol-enriched diet, they found less evidence of age-related changes.

The researchers also looked at another chemical, metformin, but found it had less effect.

Researchers divided laboratory-bred mice into four groups and fed them either:

  • a normal diet
  • a lower calorie diet from four months of age
  • a diet enriched with resveratrol from one year of age
  • a diet enriched with metformin from one year of age

When the mice were aged two years, they looked at their muscle and nerves, at the meeting point of the two (the neuromuscular junction, or NMJ) in a leg muscle. They also looked at the NMJs of three-month-old mice to see how they compared to the older mice.

Compared with mice fed a regular diet, those who’d been given resveratrol or who’d had a calorie-restricted diet showed:

less fragmentation of tissue at the neuromuscular junction
fewer areas where the nerve cells had degenerated, which would have meant that the muscle no longer had input from nerves

The two-year-old mice which had calorie-restricted diets had neuromuscular junctions that were most similar to the three-month-old mice. Metformin had little effect in this experiment.

The researchers say that this indicates less ageing as muscle fibres increase in size with ageing. But this does not suggest if the ageing was beneficial or not to the subject.

Resveratrol has been of interest to anti-ageing scientists for many years and researchers have previously shown it may be linked to a slowing of the decline in thinking and movement, at least in rodents. This study suggests a possible way this might happen.

But the results don’t tell us anything about what happens in humans. They suggest this substance may be useful for further research in humans at some point. They certainly don’t provide a reason to drink gallons of red wine, in the hope of seeing an anti-ageing effect. Drinking too much alcohol is a sure-fire way to speed up deterioration of thinking skills, and can cause brain damage. Too much alcohol in the long term is linked to several cancers, heart disease, stroke and liver disease.

Although red wine contains resveratrol, the amount varies widely, from around 0.2mg to 12.6mg per litre. That’s nothing like enough to get the amounts consumed in this study.

The mice were fed 400mg of resveratrol per kilogram of body weight each day. To achieve the same level of anti-ageing purported in the study, the average weight woman in the UK (around 70kg) would need 28g of resveratrol a day for the same effect. This would be obtained by consuming more than 2,000 litres of the most resveratrol-rich wine. An average weight man would need even more. This would be going beyond side effects and into the realm of health dangers! Or if you were disturbed by the daily consumption of this amount of alcohol, and still wanted to try, you could eat bin loads of berries – you might need fifty of these a day. What’s for breakfast? Blueberries. Snack? Blueberries powerbar. Lunch? Blueberry soup? Dessert? Blueberry cake. Resveratrol occurs naturally in the skins of some red fruits, including some grapes, blueberries and mulberries. But this rate, anti-ageing might be more of a curse.

The study was carried out by researchers from Virginia Tech, Roanoke College and the National Institute on Aging, all in the US, and was funded by the National Institutes of Health.

Is there any thing of value we can glean from this research? One certainly hopes that the whole research was conducted for more significance than mere paper filler.

The effects of rosveratol will probably hold the most interest for researchers. One can imagine that scientists will be looking to produce genetically-modified grapes that hold more of the chemical, or refine the chemical until it reaches higher levels of purity. Drugs, medication, and anti-ageing creams may contain higher levels of rosveratol. Why is there the interest in slowing down ageing? It extends beyond the obvious physical aging. Slowing down the process may also inhibit age-related diseases such as cancer, diabetes, Parkinson’s and dementia.

And while it was of little effect in this particular trial, metformin is currently undergoing trials as an anti-ageing drug. While it is one of the drugs used in the treatment of type 2 diabetes, and marketed under brand names such as Glucophage, it is relatively new as an anti-ageing drug.

Belgian researchers researching metformin found it increased the number of oxygen molecules released into a cell. When tested on roundworms, the worms aged slower, did not slow down, nor develop wrinkles. They grew stronger bones and increased their own lifespan by nearly 40%.

Metformin only costs only 10p a day which means it falls well under the threshold of QALY (quality-assisted life years) cost that the NHS uses to measure cost-effectiveness. It is conceivable that either metformin or rosveratol could form the active ingredient of anti-ageing pills or creams in the future.

And when that happens, you can read all about it in the papers again, about how red wine really lengthens your lifespan! You might even want to sign up for a clinical trial!

The British media is really drunk on red wine.

And did you know, that if it wasn’t for red wine, the world of Classical music might not have reached the dizzy heights that it did? While the link is slightly tenuous, it can be said that if it weren’t for red wine, Classical music might not have attained its popularity. Read about it here and decide for yourself.