Towards the lower end of the scale, where fingers get mashed with hammers and sinuses give you headaches, supplies are the determining factor for whether or not you can “treat” them. If you have a tweezers, you can remove a splinter, regardless of whether you’re a surgeon or a goofball. If you don’t have a tweezers, you’ll have to improvise something and again, your formal education has little impact.

Towards the upper end of the scale, though, training and experience become huge factors in your effectiveness. Whether or not you can amputate a crushed arm, for instance, has very little to do with the sharpness of your saw and a lot to do with whether or not you have any idea how to use it. (not to say that supplies don’t matter- plenty of Haitians would like you to know that vodka did not work as a sterilant.) The low-frequency/high acuity end of the emergency scale is also a “long tail”- it keeps going and going, with the relative importance of experience to materiel continuing to explode exponentially. Almost nobody, for instance, can separate conjoined twins, no matter how well equipped they are.

The question that arises when discussing first aid, or emergency medical training in general, is how much of that curve are we expected to handle on our own. Obviously, no matter what the sustainable zombie folks would like, noone can manage “everything” without recourse to a higher level of care. Quantitative goals, like attempting to handle, say, 95% of all emergencies, sound good at first, but founder on poor epidemiology (and extreme contextual variation- 95% of emergencies in Montana are not the same as 95% of emergencies in Uganda) and on a certain fuzziness at the lower end of the scale. Plenty of “emergencies” aren’t actually dangerous, even if you do nothing. When I was homesteading, my fingernails were pretty much always a catalog of fingernail-trauma; I was well within the bounds of good sense to ignore them and my fingers came out fine. What you include in your first-aid scope of practice depends on what you consider worth treating, and what you feel comfortable leaving alone; again there is plenty of cultural and contextual variation.

Somewhere, though, you have to draw the line and say “I will be trained and equipped to handle anything up to this point, and after that I will look for higher levels of care.” Everybody is going to approach that differently, but ultimately my proposal (which I was trying to foreground in the previous post) is that available training isn’t a bad place to start. If you take the fraction of problems that you are experienced in handling, declare that your scope of practice, and pack your “first aid” kit appropriately, you will at least be making a sensible decision. If you buy a pre-packed kit that lacks supplies you use every day, you’re ripping yourself off. If you buy a pre-packed kit (or build one based on internet advice, or some “how to survive” book) that contains items you’ve never used before, you are at best wasting space, and at worst posing a real risk to anyone you attempt to take care of.

If you don’t like this proposal- if limiting yourself to the familiar and easy seems restrictive- I have two pieces of advice. First, abilities and knowledge are always extensible- you can always learn more and get better at what you’ve already learned. So, go learn more. Secondly, ask yourself: what is your motivation for having a first aid kit anyway? We have a cultural fantasy about being in a desperate situation where improvisation is the only option; this is the basis of virtually every medical TV show out there, and plenty of other narratives as well. In real life, though, these situations are way, way up on the high end of the curve, and tend to end very badly. I wasn’t kidding about the Haitians, I was there- plenty of American surgeons, high on cowboy legends about seat-of-the-pants decision making and improvisational surgery, amputated arms and legs using booze-sterilized hacksaws. The results weren’t pretty- not only were a huge portion of the wounds badly infected, but Haitians stopped trusting American medical personnel. Plus, other teams were trying to avoid amputation entirely, and to my knowledge nobody has ever demonstrated that the surgical cowboys had a better survival rate (or a lower disability rate) than the conservative French or UN or Haitian doctors. Until somebody does that, all evidence will be anecdotal, but c’mon now.

Basically, to imagine that you would be able to manage an emergency you haven’t trained for is far more irresponsible than just not having a first aid kit in the first place.

What should I get with my first aid kit?

Nothing. A first aid kit is a bag, like a purse or that outer pocket on your backpack, for storing and organizing the items you use on a regular basis. Purses don’t come pre-loaded with two spare tampons, a date book, five packs of soy sauce and a plastic fork; “standard” pre-loaded first aid kits don’t make sense either. Lets look at a standard kit, say this one from CampMor:

There are things to like about this kit, for instance it has three information sources- a guide to the pack itself, a first aid manual, and an “action card.” At seventeen dollars, it won’t break your budget, and it includes a few things- tweezers, for instance- that you can pretty much count on needing sooner or later.

On the other hand, its kind of silly and makes some obvious compromises to make “one size fit all.” It includes two ibuprofen. Two? I can get a generic bulk pack from the drug store and put as many in as I want. Or, maybe I’d like tylenol instead, or naproxen? Why waste time and money on an “included” two pack? Also, the kit contains a green soap sponge and steri-strips. Both potentially very useful, but only if you’re out on your own for a significant period of time, and if that were true and you had a wound requiring surgical scrubbing, you’d probably want more than two ibuprofen, right?

It doesn’t, however, contain my favorite bugbear of an “included” first aid supply, the abdominal bandage or “ABD Pad”:

In my time on the ambulance, I probably used five to seven ABD pads. Now, I needed every single one of them, but in the same period of time I probably used five to seven thousand glucometer test strips. What I’m getting at is that the contents of your first aid kit should be based on what you use the most, which in turn depend on the context in which you might end up needing them. If you’re going to an earthquake zone, a “first aid kit” could be a duffel bag full of ortho boots and collapsible crutches. If you’re an ultralight hiker in a temperate climate, you might prefer telfa for blisters, or sunburn ointment. If you’re a wildlife biologist in Minnesota, your first aid kit should include things like hand warmers and something for giardia. If you or your family or nine percent of the population in your country are diabetic, you should probably keep a glucometer and test strips handy.

But what if you don’t ever use first aid stuff to begin with? Well first of all you probably do- go to your medicine chest, pick the six least dusty items,* and put them in a bag, voila. But more importantly, maybe you don’t need a first aid kit right now- maybe you need first aid training instead. Its a little weird to be saying this about bandages, but extend the principle up the scale: it isn’t uncommon on the internet to come across people asking “what antibiotics should I keep on hand?” The answer is none. If you know how to use antibiotics safely, which ones to keep is a no-brainer, hardly worth asking in public. If you don’t know how to use them, you shouldn’t have them around. First aid, while less risky, isn’t too different- knowledge, not doo-dads, is what saves lives in an emergency.

So get some first aid training! If you live in the US, first aid and (better yet) first responder training is pretty much universally available through the Red Cross, American Heart Association, NOLS, even FEMA; I assume some similar opportunity exists in the rest of the developed world. If you have a few months, most community colleges offer EMT training, and you could gain all the experience you need to build your own perfect first aid kit with a mere year with your local Volunteer Fire Department.

Now, I’m the first person to agree that medicine isn’t nearly as hard as its made out to be. We live in a culture that makes medical school graduates seem near-godly, whereas physiologists, public health workers, physical anthropologists and, (duh) nurses all learn the same material without so much as a whicker. Plus, plenty of people take good care of sick or injured people without ever learning chemistry or optics or even what we think of as “modern medicine.” I don’t want to be accused of saying that you need some paper on your wall, or some letters after your name, to be able to provide really good health care, because I absolutely think that premise is bunkum. What I will say, though, is that there is absolutely no substitute, for you, for the aid worker with the copy of Where There Is No Doctor, or for the arrogant new doctor entering a residency, for personal hands-on experience. Whatever you’re doing, if you want to be good at it, you have to have done it before. If your mother was a traditional healer, and you can sit at her side for ten years, wonderful. For most people, the easiest way to get that experience is by jumping in on the citizen-participant level and keeping their eyes open.

No, no, I mean where there REALLY is no doctor!

But, of course, this is the internet and nobody’s happy with that. On my one side are people talking about “sustainability,” on my other side are people worried about the zombie apocalypse; both of these groups like to criticize standard first aid for being too much “first” and not enough “aid”- that is, for teaching providers to expect ambulances and emergency rooms will be available within no more than a day or so at most. These folks actively resist getting trained, for fear they’ll pick up too many bad habits and dependencies in the process. What about when there’s no good backup plan?

First, lets stop a minute and think about what you’re asking. You want to know how to provide definitive medical treatment with no outside resources whatsoever, in a life-threatening emergency, with no prior experience and no information beyond what you’ve read online or in a book. You aren’t asking about real life, you’re asking about a video game.

Are there emergency procedures that can work in crazily resource-isolated circumstances, that doctors generally don’t learn? Sure. Most of them have been abandoned for a reason, such as not comparing well to more resource-intensive modern alternatives, but there are a few forgotten gems out there. Unfortunately, in my experience, its predominantly formally-trained medical people who collect them- WALS classes tend to be taught by doctors, for instance. Plus, the value of experience applies here too: I’d definitely want to have a pretty solid understanding of what I was doing in non-crazy circumstances before heading off into the radioactive wasteland, and for that my earlier recommendation (join the VFD) works.

However, in the interest of keeping my readers happy, I hereby present:

What should I put in my sustainable zombie apocalypse survival first aid kit?

Answer: a sheep.

Wait wait, I’m serious. Think about it. Wool can be knit into warm garments against cold exposure, or woven into steam-sterilizable bandages. Lanolin from raw fleece is good for a wide variety of skin complaints. Boiled sheep leather can be used to make a custom-formed splint. Sheep intestines are the traditional source of gut sutures, and the cecum can be made into a “lambskin” condom. The greenflies that infest sheep farms are the source of wound-debriding maggots, and in an emergency, a ram’s horn can be carved into a shofar to call for help. Sheep are self-reproducing, don’t compete with humans for food, and in a pinch are good against malnutrition as well!

Got it? A sheep.

*- in my case: tylenol, diaper lotion, bandaids, non-latex gloves, chapped-hand ointment I made myself a few years ago, and alcohol pads. My “medical bag” (which started as a craftsman tool bag that I kept my stethoscope in for clinicals) contains dental floss and sewing needles, wire cutters, and a tuning fork.

Here you can listen to a RadioActive interview with the editors.

Also, for those who miss the energy of Occupy, please, go take a look at what the Anti-Keystone XL Pipeline folks have been getting up to in Texas. Better yet, go pitch in- they need you. (Z, this is your backyard, so I’m talking to you directly here)

A

They say this place is a really good hospital. Surely not because of their definition of “parent.” A parent can be biomom, biodad, or biomom’s husband; biomom’s unweddable female partner doesn’t exist. No, this is a “really good hospital” because a manager gives the admission worker a clear instruction to ignore that definition. We go upstairs with matching parent badges.

I haven’t been writing entries here. We had a baby. He aspirated poop. He’s beautiful- every baby is. Now he has tubes in his nose.

My only title here is mom. Believe me, its enough. This ward, like all American health care, runs on nurses- nurse practitioners manage the care plans and nurses manage the patients. Medical students, notoriously, labor under the misapprehension that they manage the nurses, and I’m not here to antagonize anyone. My close-to-college address has provoked the question only once; I demurly identify as a grad student.

For all the machines, this is a human space, and language and names have power. I worry that my easy familiarity with the jargon will expose me. “The monitor’s saying he desatted, but the probe has no waveform and his respers are good; no flaring.” I use metric measurements and reflexively throw the diaper on the scale. Then I overhear other parents and we all talk the same way. We are refugees in a strange country; we learn the language to survive.

The first night we meet a first-year resident. She is very upset that we skipped the erythromycin drops in his eye. We explain that we know mom’s GC/herpes status is negative. “You need to understand” she says. We do understand- she has to report to someone else. She promises to return with a form for us to sign. A minute later we overhear the NP telling her there is no form “but you can document you talked to them if it makes you feel better.” We never see her again.

We understand ourselves too. Refusing erythromycin is harmless, and a powerful gesture to remind ourselves: this is our kid, even here.

In the parent area a large family sits with a doctor and an NP. They are talking about Down’s syndrome. “Do you have any children?” I ask the cleaning lady. Her one son is 26. Her other son died. There is no escape.

This is a progressive facility. The staff believe in sun lamps, room-air CPAP, breast feeding- my god do they believe in breast feeding. It must be hard not to breast-feed here. There are porta-pumps, pump rooms, lactation consultants everywhere. By day three he is no longer receiving any other medication.

They also believe in “kangarooing”, which you could also call “Harlowing” or just “holding your baby.” “Sessions start at one hour” reads the color promotional poster on the bathroom wall, “and may be increased to three hours.” Three hours is the interval between weighings and diaper changes. There’s (almost) no other reason to put him down, so we don’t.

The poster is brilliant by the way. The photo models are a smiling black mother in an isolation gown and a tough-looking white guy with a bad shave. You aren’t too hard for this, it implies, and your baby is not too sick.

We have one nurse who is uncomfortable with all the holding. She would prefer it if we call her for help when we transfer him back and forth. We wouldn’t want him to pull out his IV line again, or his OG tube. She is very young. We think she means “dear god in heaven, let me never put in an IV or an OG tube wrong”
“dead god in heaven, maybe if I don’t have to put in any IVs or OG tubes at all”

The most important things are small things and can’t be put into words. How to double-secure an IV. How to secure a CPAP mask using only the straps. How to do it with your thumb. Under the bili light, the nurse tucks an extra blanket under the foot of his U-roll and he goes from squalling to sleeping instantaneously. I repeat this myself later, and a new nurse calls me “the baby whisperer.” This is my real medical education.

Every family is different. In one bed a grandma holds her granddaughter around the clock. Another family shows up in matching “its a girl!” shirts. One mom is in a wheelchair, clearly a recent change in her life. We worry about the baby next to us, then the parents finally show up. He is wearing the torn jeans and cement-flecked workboots of a day laborer. In poor English he apologizes for their transportation problems. She says nothing at all. On TV, Mitt Romney is complaining about Americans too poor to pay income tax, calling them dependents who “think they’re victims.” There is no escape.

The nurses can’t understand why we have a pack of diapers on our parent shelf. Does he need special diapers? No, we just have what we were carrying when the ambulance came. My sister-in-law brings us clean underwear and a nail clipper.

The lonely babies get a mobile and a NICU-issued electronic music box with a bizarre playlist. Frere Jacques shares duties with the Battle Hymn of the Republic and Dvorak’s New World Symphony. Its like being in an amateur ring-tone factory, especially when more than one box is playing at a time. A nurse reports hearing a father hum Frere Jacques in the hallway.

The above was transcribed from my notes. We are home now.

This article however, from the Kansas City Star, comes due for some absolutely outrageous scorn.

For those of you afraid to click the link (its safe for work!) the headline is at this time: “Doctors dispute Akin’s claim, but some supporters say it was misunderstood” in reference to Missouri senate candidate Todd Akin’s statement that women’s bodies reject pregnancies initiated by rape. First of all, that only barely qualifies as a claim, and to say that doctors “dispute” the truth value is weird to start out with. This isn’t a dispute with Todd Akin on one side and the entire lived experience of the human race on the other; Todd Akin’s statement has no truth value in consensus reality, period.

The truly objectionable part is as follows:

Michael Weaver, an emergency medicine physician at St. Luke’s Hospital and medical director of the forensic care program at St. Luke’s Health System, said Akin was wrong.

“To try to be able to say that anyone’s going to respond in a consistent pattern that’s going to limit their probability of becoming pregnant is ridiculous,” Weaver said.

But Tim Wildmon, president of the American Family Association — a nonprofit that describes itself as a pro-family organization — told The Star on Monday that “fair-minded people” know what Akin really meant by his statement. Wildmon speculated that Akin was differentiating between forcible rape and statutory rape, which can be consensual.

“What I read from some medical sources, when a woman is raped, her body shuts down in some respects that may prevent her from getting pregnant,” Wildmon said.

Wildmon referred to an article by physician John Willke, president of the Life Issues Institute — a nonprofit anti-abortion group — and former president of the National Right to Life Committee. In that article, titled “Rape Pregnancies are Rare” and published in April 1999, Willke wrote that one of the most important factors to consider is that a rape victim’s hormone production during such trauma may be “upset,” resulting in a possible pregnancy being compromised.

First, why an ER physician? I mean, sure, ER physicians are smart and all, but is this even something that warrants a pull quote by an individual? Why not “in preparing this story, we were unable to find a single physician willing to go on record claiming that raped women don’t get pregnant.” Secondly, even if they do quote Dr. Weaver (who may be a pillar of the community in Missouri, I just don’t know) why do they counterpose him with a political advocate who merely repeats, almost word-for-word, what Akin said in the first place? In letters-to-the-editor-speak, this is called “and my girlfriend thinks so too” and doesn’t mean anything.

But finally, Willke has exactly two cites in google scholar, both are books for lay readers on abortion. That “article” (which you can read for yourself here) begins with the assumption that from a given number of rapes, only two thirds are fertile due to age(!), and continues to rule out individuals statistically based on whether or not a woman is ovulatory, using oral contraception, a few BS numbers relating to “well it takes a normal couple so long, so there must be some factor that reduces it by X,” claims that women who get pregnant by rape and then miscarry don’t count, and finally decides that only 450 or 740 (depending on how literally you take his math) women are actually pregnant by rape in a given year. Then he makes the following claims:

Finally, factor in what is certainly one of the most important reasons why a rape victim rarely gets pregnant, and that’s psychic trauma. Every woman is aware that stress and emotional factors can alter her menstrual cycle. To get and stay pregnant a woman’s body must produce a very sophisticated mix of hormones. Hormone production is controlled by a part of the brain that is easily influenced by emotions. There’s no greater emotional trauma that can be experienced by a woman than an assault rape. This can radically upset her possibility of ovulation, fertilization, and implantation.
What further percentage reduction in pregnancy will this cause? No one knows. but this factor may well cut this last figure by at least 50%, which would make the final figure 225 (or 370) women pregnant each year from forced rape. These numbers closely match the 200 that have been documented in clinical studies.

Needless to say, he doesn’t produce any citations.

So, that’s the KC Star’s “dispute”- a “no-one knows” speculation tucked at the bottom of an advocacy group’s talking points website, versus all of human experience and medical knowledge. Way to go, Kansas City Star.

(Yes, you have my blessing to go harass the comment chain.)

Data points are for 50 states plus District of Columbia

2011 Obesity data from the CDC: http://www.cdc.gov/obesity/data/adult.html
2011 Political affiliation data from Gallup: http://www.gallup.com/poll/125066/State-States.aspx

I’m going to go out on a limb and suggest that we don’t know, won’t know, and will never be able to “predict” what turns a reasonably stable person into a shooter. There are permissive traits that show up in a lot of these cases- most are young white men, for instance, and antisocial personality and a recent onset of schizophrenia seem to be common as well. However, the prevalence of schizophrenia is higher than the prevalence of type I diabetes, and while I don’t have any data on antisocial personality in front of me, its hardly rare. Most schizophrenics live unhappy, manageable lives full of medication side effects and anxious self-monitoring, but they do not kill; those who do almost always have exactly one victim- themselves. The fact is, narrowing the “killer profile” down to a few hundred thousand people is never going to help identify individual suspects before they go off. Mass shootings like this will always be black swans.

Nonetheless, reading a news article at the LA Times, one finds a number of comments like one by someone calling themself gruinchooch which I will quote in full:

“The suspect in the Colorado shooting Friday was described as a shy but polite…” where have we seen this type of mass-shooter before? Gee, I am guessing just about all of them. What is it that can possibly be amazing about a person that has problems engaging with others would also have less of a problem…? The one I would like to see {no, not literally} is a: “… the shooter was described as warm and outgoing; always willing to lend a hand or a shoulder to his neighbors and even strangers…”

“We were all people who didn’t have go-to best friends, so we all ate lunch together.”; “dark, sarcastic kind of humor”; “…but he didn’t make a big effort to make friends.”; “…he wasn’t notably introverted within their circle.” (note: notably); “…but had begun the process of withdrawing from the program last month, officials said. “ Weren’t the flags RED enough?

Point is, no. These flags aren’t red at all. One of the weird effects of the Columbine killings in 1999 (yes, I’m old enough to remember) was an outpouring of identification with the killers, from everyone in the country who’d been bullied in high school, been called weird, or decided to wear strange or intimidating clothing and hang out with a small clique of similarly attired outcasts rather than follow the fashion trends of their day. This was a mistake- subsequent analysis of Eric Harris’ diary has suggested that he had far deeper problems than just being picked on- but it has echoed through the aftermath of every subsequent mass killing. Yeah, I used to think about blowing up the school too…

But I didn’t. Neither did any of my friends. Neither did any of the other people who thrilled to hear Marilyn Manson (in Bowling for Columbine) say that he would have stopped to listen to those kids, because feeling awkward and outcast and picked on in high school- and feeling angry about it, too- is normal, and actually triggering explosives is not. This is the distinction that is inevitably lost in the post-event “profiles” of mass killers. There is no justification, no diagnosis, no personality, no religion or political position, that makes mass murder normal. It will always remain sui generis. Even for angry schizophrenics facing stressful exams.

After Seung Hui-Cho killed 32 people at Virginia Tech in 2007, there was a call for “better identification” of college students with mental health problems. I hope everybody out there takes this seriously; we have cultural problem with recognizing and acknowledging mental illness. If more people are able to say “hey, your work in my class has deteriorated and you seem somewhat remote, is everything okay?” we may well reach the point where fewer college students commit suicide, or drop out, or spiral into addiction or bad relationships. But mass shootings? Forget it.

And correspondingly, lets not start implementing the kind of punitive or preventive measures that confine or exclude crazy folks “for the safety of the public.” I’ve had doctors tell me- off record, of course- that they only ever diagnose bipolar disorder, not schizophrenia, because they can give someone the same medication without costing them their security clearance or their job. Any time there’s an increased penalty to self-identifying as crazy, fewer people will seek whatever treatment works for them.

To all the other med students out there (who are heading into the profession with the highest risk of suicide, supposedly) who are getting boards scores back- kick ass!

Best,
A

Sometimes when facing common trouble
When whole town is screwed
We become actually human
Act like Prometheus would
Suddenly there is more humor
And a party tabor style
People ringing one another
“Yo man, how was your blackout?”
Suddenly there is more music
Made with the buckets in the park
Girls are dancing with the flashlights
I got only one guitar!
And you see brothers and sisters
All engaged in sport of help
Making merry out of nothing
Like in refugee camp

Oh yeah Oh no, it doesn’t have to be so
It is possible any time anywhere
Even without any dough
Oh yeah Oh no, it doesn’t have to be so
Forces of the creative mind are unstoppable!

And you think, All right, now people
They have finally woked up
But as soon as the trouble over
Watch them take another nap
Nobody is making merry
Only trotting scared of boss
Everybody’s making hurry
For some old forgotten cause
But one thing is surely eternal
It’s condition of a man
Who don’t know where he is going
Who don’t know where does he stand
Who’s dream power is corked bottle
Put away in dry dark place
Who’s youth power is well buried
Under propaganda waves
Who’s dream life is in opposition
With the life he leads today
Who’s beaten down in believing
It just kinda goes this way!
Oh no, it doesn’t have to be so
Forces of the creative mind are unstoppable!

(Gogol Bordello – Oh No)

If you google “hunter gatherer” and page past all the weight-loss diets, you eventually find people who both study cultures with less material technology and also envy them, and inevitably somebody is saying that “primitive” people (or “primitive tribes”) had more free time than modern humans. And, equally inevitably, you will find people passionately arguing that no they didn’t, they had to work all day or starve. Its time to put that question down.

Folks, “free time” is a culture-bound concept. You just can’t make comparisons. Its true that stone-age (or even bronze-age) hunter gatherers had no concept of grinding away hours in a cubicle, but neither did they have a concept of kicking back with a pouch of roasted crickets and catching up on their hero-goes-over-the-mountain-song. Many things I do in my “free time”- gardening, or foraging- would have seemed like work to a paleolithic band. Conversely, things I do as “work”- long conversations, learning healing techniques, formulating and expressing opinions on abstract concepts- were day’s-end activities once upon a time. You just can’t compare.

Furthermore, even if you look at work done so as not to starve, the comparisons become difficult, because humans worry as much about social prestige as they do about survival, often much more. I wrote here about JD Speth’s conclusion that paleolithic big game hunting (as opposed to the 4R-staples- rabbits, rodents, reptiles, arthropods, plus eggs, birds, fish and molluscs- which made up the bulk of the animal component of attested pre-metal-tool diets) was primarily a prestige activity, and hunters generally experienced a net caloric loss. Does big game hunting count as work, then? Even considering that the time would have been better spent- with a hit to one’s social status, of course- digging out marmots? On the modern side of the balance, Americans spend 9.8% of their income on food, does that mean that the other 38.786 hours per week should be figured differently? (that’s 90.2% of 43 hours by the way) Surely at least some of the income so generated goes to prestige activities, so the work done to obtain it is no more “for survival” than the time spent at home making yourself a really cool date hat. Furthermore, about half that food money goes to prepared food- if you could concievably survive on much cheaper bulk staples (and be healthier) are you working for food for survival? Or for prestige?

Basically it makes no sense to make that sort of comparison.

And while we’re disputing romantic primitivists and their detractors…

Yes, Christopher McCandless died. People say he was reckless and stupid, and argue about whether he actually starved to death, or whether he was poisoned by swainsonine in wild peas. Either way, he could have self-rescued, except that the Teklanika river that he crossed in dearth in April was in flood in July. Folks, if he had been truly reckless and stupid and tried to cross it, he’d have been one of the 136 Americans who drown every year in Alaska and you’d never have heard of him. Instead, he was the one guy who starved.

As much as it annoys me to see people romanticize “primitive” cultures (they’re fine, okay? they’re just more people!) it makes me more angry when fans of “Survivorman” or whatever try to make living in any way off the land seem incredibly dangerous, especially if you aren’t armed with 20 pounds of sharp metal and an ALICE belt. If you’ve ever wondered what are the most common causes of death in the wilderness they are as follows: number one, heart disease. Number two, drowning. Number three, falls. Number four, car crash. Sure, most people don’t drown in the suburbs, but the rest is familiar stuff. Stop making the woods look scary!

In general, people who die in the woods are people who came out for a short period of time. Why? Because that’s who’s in the woods. People who decide they’re going to live in the national parks, or whatever, generally get bored and lonely and walk out alive. For every Christopher McCandless there are probably thousands of people who went on a really long adventure and just lost a little weight. Talking up the danger level may make you feel tough and macho for your brand name axe and knife combo, or may help you rationalize spending your vacation playing Skyrim, but it also keeps people who would have a blast walking the PCT, say, from going out and trying something new. And who knows, maybe we will get some real low-tech refusenik nomads one of these days!

(And only a few mushrooms are seriously poisonous, and some of the really good ones look nothing like them- but learn from a person, not the internet)

(thanks to Ran for reflecting the “stop making the woods look scary” rant back to me in an intelligible way)

Its All Because of Agriculture!

This one I confess puts me on shakier ground. The theory goes, livestock are routinely dosed with antibiotics, and hence resistance develops in livestock and crosses over to humans with devastating results. There are some things to like about this theory as a source for resistance mutations, and some things that are questionable. First, though, the core allegation is true- healthy livestock are routinely dosed with antibiotics not to prevent clinical disease but because they gain more weight that way. This is probably a terrible thing- why would we want to be eating the residues of chemicals that induce extra weight gain?⁶- and it certainly goes along with some other horrible livestock practices (why bother keeping your cow clean if the antibiotics knock out the disease?) and this isn’t the forum to discuss them.

However, not only are some of these antibiotics never used in humans, they sometimes work by methods that are never attempted in human antibiotics. Some bacteria have evolved resistance to drugs never used in livestock.⁷ Furthermore, some of the worst zoonoses of recent years have developed not because of antibiotic exposure but because of other changes in livestock raising- E. coli adapted to live in the acidic rumens of grain-fed cows are less susceptible to acid-killing in human stomachs, for instance. And of course, the transmission of livestock diseases to humans is as old as animal husbandry- measles, smallpox, anthrax, plague, basically any disease that has ever accidentally an entire civilization probably developed from a livestock or farm-pest host.

The only thing I feel comfortable asserting here is that while mass-dosing livestock is probably bad, it seems unlikely that antibiotic resistance would have been avoided if we hadn’t taken to overmedicating our dinner. And certainly, it won’t go away if we stop.

African Nurses/Ignorant Hicks/Overprotective Parents

Remember when I said western medicine loves its personalistic theories of disease as much as any “primitive society”? There was a comment on that Telegraph article blaming the whole problem on the British National Health Service hiring too many “African Nurses” who don’t wash their hands. Similarly, you hear plenty of stories (even in med school) about how antibiotic resistance is caused by hicks who take antibiotics randomly whenever they feel sick, probably at the wrong dose and for the wrong period of time, maybe they got them in Mexico. In a gentler form, you get the panicky instructions to “take the entire dose, don’t stop when you feel better!” And my third personalistic cause up there relates to the belief, common in the US, Britain and (weirdly) in Russia that “modern” children are too weak, due to having not been allowed to play in the mud and develop resistance to pathogens.

There are elements of potential truth in all of these, except the “African” part (i.e. yes, poor hygeine in hospitals is a problem, but not one that has to do with race or continent of origin) but they are also silly ways of blaming people who are already seen as targets.

The “take all the dose” theory is actually less secure than you think. When dealing with other organisms (say, frogs) and other environmental stressors (say, cold) where resistance is complex and polygenic, exposing the organism to a lower dose of a stressor for several generations selects for offspring more likely to survive at sequentially higher exposures. Hence, if you want frogs on top of your mountain, you’re better off breeding frogs from midway up the mountain than you are breeding frogs from the valleys. The problem is that bacterial resistance isn’t usually polygenic- one mutation, a different ribosome, a different membrane-assembly, an extra efflux pump, and your bug is resistant. Some of these mutations don’t even occur de novo- plasmids are little bits of circular DNA that travel between species as well as between organisms, and plasmids frequently carry resistance genes in their entirety. One copy of a plasmid, in any of the bazillion bacteria in your body right now- on your skin, in your gut- could proliferate to convey resistance to an enormous range of pathogens with very little difficulty. According to a microbiologist I asked (couldn’t find any rigourous studies⁸) resistance develops as quickly in fully-treated hosts as in half-treated ones. The key necessary and sufficient conditions are a population of bacteria and exposure to an antibiotic, nothing more.

So What Do We Do?

Well, the first thing is relax. Even people who study disease extinctions in mammals talk of islands or island habitats. Ross MacPhee claims (and I wouldn’t question him!) that no continentally-distributed mammal is known to have been wiped out by infectious disease. So, this isn’t the end of humanity. We lived a long time with our pathogens and our 50% pneumonia mortality and we’re still around.

The second thing to do is to go back to those questions about avoiding exposure and improving metabolic and immune health. Public health measures may have been more important than vaccination or antibiotics in reducing deaths from infectious disease in the twentieth century⁹ and there’s no evidence that basic surveillance, screening, and simple targeted countermeasures will be less effective in a hundred years than they are today. The only major novel epidemics of the twentieth century occurred in holes in the public health safety net- Spanish Flu hit while most of the world’s health departments were shattered by warfare, attrition, and war-inhibited communication. Had Germany and France been sharing medical info, things might have gone differently. HIV was deliberately ignored by politicians who couldn’t get past their own homophobia (and in other countries disdain for IV drug use and prisoners.) (uh, and racism) (and puritanical reluctance to engage meaningfully with STDs, see also Tuskegee) (okay, HIV was a hell of a special case.) Emergent diseases are now so closely watched that you can get regular email updates several times a day. Untreatable diseases like SARS and Ebola regularly crop up and are contained without any medical therapy whatsoever, purely on the strength of a solid, well-informed global public health sector.

The third thing is to avoid stupid panicky ideas. I’m not a doctor (yet) so I can’t give you real medical advice, but I’d be pretty surprised if bathing your children in bleach to prevent MRSA turns out to be a good idea. Likewise, a study that keeps bouncing around suggesting tea tree oil is better at killing MRSA than chlorhexidine is only interesting if you know the difference between colonized and active infection. It kills the random MRSA bugs living on your skin. The study didn’t even look at treating people with folliculitis or abcesses or “spider bite” (I’ve lived and worked in brown recluse territory most of my life and never seen a “spider bite” that wasn’t a staph infection.) Even with antibiotic resistance on the rise, your chances of developing a resistant infection are still a lot less than your chances of getting diabetes, or heart disease.

The fourth thing, and this is the hardest to talk about or hear, is that there might not be anything to do about it. This may just be the shape of things. Its a weird disorder of western thought that problems have solutions, or that people who don’t have solutions shouldn’t discuss problems. Bad stuff happens. Tuberculosis is already making a comeback. Who the heck knows?

A

6- compare the effects of rumensin with my hypothetical mitochondrial toxin some day
7- for instance the penems in the Greek penem-resistant Klebsiella aren’t used in livestock
8- …but I’d love to see one!
9- this is not a debate I want to wade into, but I tend to think its probably a fair claim