response and further comments on: e coli superbug is spreading

an article was sent by burak alsan, from an interview with his wife marcie alsan (see http://blogs.plos.org/publichealth/2016/05/31/to-fight-superbugs-fight-poverty/).​ she stresses the connection between socioeconomic disparities and infectious diseases, specifically noting that "out of pocket payments were the most significant correlate of antimicrobial resistance across countries" and that "the entire correlation was driven by countries that had in place a policy by which copayments were imposed in the public sector". In particular, she found that of 47 countries, out-of-pocket health expenditures were the only factor significantly associated with antibiotic resistance, controlling for socioeconomic and environmental factors (eg sanitation, animal husbandry, and poverty) and structural health-care features (eg physician density, hospital bed density, total health expenditures). in particular, a "ten point increase in percentage of health expenditures that were out-of-pocket was associated with a 3.2 percentage point increase in resistant isolates". for details, see antibiotic resistance and outofpocket costs lancetinfdis2015 in dropbox, or Alsan, M. Lancet Infect Dis 2015; 15: 1203). 

commentary
--I think this is really important. I mentioned out-of-pocket expenses in my rantings on one of the fundamental problems with our health care system: we do not place primary care at its center. Providing easy access to primary care is not only much cheaper to the system but undoubtedly derives better outcomes, with more coordinated, less interventive care that prioritizes a more holistic approach to the broad biopsychosocial aspects of the patient and focuses on the therapeutic benefits of a strong provider-patient relationship. all of this means having free and easy access to primary care (decreasing obstacles to access, such as copayments by patients), as well as reorienting the incentives in the system to promote the training and job satisfaction of primary care providers.
--and, as mentioned before, i have seen way too many patients with treatable conditions (eg, cellulitis, hypertension...), unable to pay their copays for meds, then hospitalized with serious conditions (sepsis, stroke...). a huge human as well as monetary cost...
--in the case of antibiotic resistance, there was an article in the Boston Globe today finding further spread of colistin-resistant E coli, noting a few pretty scary things: this "superbug" was found in another pig in the US, but concerningly enough "each of the three US cases (2 in pigs, and the one woman from Pennsylvania) involve different strains of E. coli. The latest animal case suggests the gene is spreading through multiple routes here." (see https://www.bostonglobe.com/news/nation/2016/06/14/superbug-found-second-pig-sample/OPUjpJ5aMA7ontXAjMW4xL/story.html ). seems like a pretty urgent thing to tackle....

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