I went to college in Connecticut. Deal with it.

Perhaps because it’s college graduation and reunion time, L.V. Anderson at Slate has written a column entitled “People Still Say They ‘Went to College in Boston,’ Meaning Harvard? Please Stop Doing This.” She claims that by giving such an evasive answer, one “buy[s] into the overblown mythos of Harvard and the presumption of Ivy League superiority.” Or worse, it “functions as an elitist dog whistle,” and that those who may “react inelegantly” upon hearing one went to Harvard/Yale/Princeton and others are “insecure people who perhaps have not yet learned that Ivy League schools confer degrees on plenty of idiots every year.”

Um, wow.

Here is why I usually say “Connecticut” or “New Haven” when I’m casually asked about college  by passing acquaintances: it’s just so much fucking easier in almost all situations. Perhaps because Anderson lives in Brooklyn, and as she notes, works with colleagues who “have degrees from universities that rank highly on U.S. News and World Report’s annual list,” she runs in circles with many of those who do understand that Ivy League schools confer degrees on plenty of idiots every year. Great for her. This is not universal. 

Let me suggest that she spend some time in flyover country. Where I come from in rural Ohio, very few people give a shit about Yale, or Harvard, or MIT. At my high school, way more people aspired to attend universities in the Big Ten than in the Ivy League. I’d not even heard the term “safety school” until my first week at Yale, or realized that so many in my Yale class considered institutions like Wellesley and Swarthmore to be such. (To be honest, I’d never heard of those colleges, and didn’t even know where Yale was precisely located until I applied. Somewhere out east was my best approximation). My alternate schools were both institutions in Ohio rather than the typical Ivy backups.

The Ivies just aren’t on the radar for many of us outside of the coasts, even those who could be prime Ivy material. Even Yale acknowledges this, as I wrote before–calling students in these states “low-hanging fruit” and claiming that we are tough to find. Over the years, even though I’ve enjoyed attending reunions and keeping up with my classmates, I’ve felt increasingly distant from my alma mater. Anyone surprised that there’s no “Yale Club of Cedar Rapids”?

So when I’m here  in “flyover country” and discussing college, I’ve found in my 20-year-experience as a student and alumna that to bring up Yale in many circles is to do just what Anderson is accusing those who say “Boston” or “New Haven” of doing: buying into the overblown mythos of Harvard and the presumption of Ivy League superiority. Really, what conceivable reason do I have to name-drop? To many here, Yale might as well be Mongolia–people travel there about as frequently, and understand it about as much. It’s practically mythical, and those who’ve gone there may as well be unicorns when it comes to the frequency of encountering an Ivy alum in many areas. The Ivies are places of Romneys and Bushes and Kennedys, where people shit gold bricks and dress like this:

How Ivy Leaguers probably look on campus, to an average Midwesterner.

As such, it creates an artificial distance between myself and those I’m conversing with. I “other” myself by saying that I graduated from Yale. This might not be important in Anderson’s line of work, coaxing other upper-middle-class foodies to “go ahead and eat the cookie dough,”  but when I’m out speaking with farmers and other community members in the rural Midwest,  or meeting with potential students coming to a state school, you can bet that my background from a farming area in Hancock County, Ohio is way more important and relevant than my four years spent at Yale. 

As Anderson should know, some of these conversations come down to knowing your audience. In Brooklyn, or in workplaces that are Ivy-heavy, I may agree with her. Maybe they’re really being faux-modest if they answer the inquiry about their college with “Boston” or “New Jersey.” In my professional biography I put Yale, and certainly will say that to academic colleagues when the topic comes up. But she’s flat-out wrong when she claims that “there is never any reason to answer the direct question ‘Where did you go to college?’ with an evasive half-truth.” In many of my conversations, I just don’t see the point in going into it, and in the past, it’s made both people involved feel awkward. If this makes me a “patronizing, self-serious jerk,” so be it. I’m the one who gets to claim my identity and own my biography, and I’m fine with being one who went to college in New Haven.

 

What is the harm in agricultural-use antibiotics?

After this post on antibiotic resistance, many of you may have seen an exchange on Twitter calling me out for being “knee-jerk” about my call to action to do something about the overuse of antibiotics. In that post, I focused on antibiotic use in agriculture, giving only brief mention to human clinical use. There are a number of reasons for this, and while I didn’t discuss them extensively on Twitter, I did want to provide an overview here in order to better explain my position and concern about antibiotic use in agriculture.

How are antibiotics used in animal production?

To start, some background on the issues. Antibiotics are used in agriculture in a number of different ways. Like humans, they’re used to treat disease when animals get sick. This type of use isn’t disputed for the most part–no one wants animals to die from treatable disease, nor do they want sick animals to enter the food chain. Antibiotics can also be used to prevent disease, such as when animals are stressed (as when they’re moved from farm to farm) and disease has a tendency to break out, or if a few animals in the herd are sick and owners want to prevent the rest of the herd from falling ill. This type of use is somewhat controversial, and many have argued that this type of use is only necessary because hygienic conditions on farms aren’t up to snuff–and that if better husbandry was practiced, this prophylactic use could also be significantly decreased or eliminated. Others argue that it’s necessary even with good husbandry.

The practice which is most widely disputed is the use of antibiotics for growth promotion. We’ve known for roughly 60 years that animals, when fed antibiotics at low doses (below the level required for disease treatment),  grow to their slaughter weight faster (and therefore, with less food input). This is the “low-hanging fruit;” the practice that even some in industry agree could end with pretty much no (or minimal) side effects to industry; and the practice that the European Union has already ended. It’s also the target of FDA guidance 213, which asks the phamaceutical industry to voluntarily phase out the use of growth promotant antibiotics in feed and water given to livestock. Twenty-five of 26 companies have agreed to this already, so again, there’s really not much dispute that this is a process that will be ending, after over 60 years of use and 45 years after a government report suggested that rising rates of antibiotic resistance in humans was tied to agricultural antibiotic use in the Swann report. (Maryn McKenna has a great timeline of other developments here).

Why am I (and many others) concerned about the use of antibiotics in agriculture?

First, and most compelling to me, is the fact that between 70-80% of all antibiotics used in the United States are used in agriculture. I’m linking to a PolitiFact report because they drill down into the caveats with that number in more detail than I want to go into for this post, but I will note that it’s tough to get good numbers because the industry won’t release them, and that the numbers we do have include drugs that are not used in human medicine–but that doesn’t mean they may not be important. More on that later.

Second, this is my area of expertise. I study antibiotic-resistant pathogens in the agricultural environment, so naturally this is my interest and where I know the literature the best. Third, antibiotic use in agriculture just isn’t as intensively studied when it comes to methods to reduce antibiotic-resistant microbes that may emerge from this setting. In the hospital and clinics, patients need a prescription to get antibiotics. The amount of antibiotics that are prescribed are tracked and those data are available. Hospitals often have stringent infection-control policies put in place to reduce the generation and spread of antibiotic-resistant “superbugs.” Hell, there’s enough research on these policies that my colleagues have a blog devoted just to that topic. In human medicine, no one is ignoring the generation and spread of resistant pathogens.

None of these control and monitoring policies are present on livestock farms as a matter of routine. Rather, as my colleague Lance Price has noted more than once, if he was going to try to create a superbug, farm use of antibiotics–subclinical dosing of thousands of animals at a time–would be an ideal way to create one.

What if we remove “growth promotant” antibiotics?

What remains an issue is what will happen after growth-promotant antibiotic use is stopped. There is already a “natural  experiment” going on in the EU, where such antibiotics were banned back in 2006. As I noted here, the results have been mixed when antibiotics have been removed from agricultural practices. Sometimes resistance persists, sometimes it goes down. A modeling paper examined the use of antibiotics for agricultural use, and suggested that their biggest impact happens before we even realize it via surveillance, and by the time we notice it, it may be too late to make much of a difference, which is depressing.  So even if antibiotics are banned for growth promotion purposes, there is a chance that we won’t see much of a dent in antibiotic resistance overall–or if we do, it may take years to see it decrease. This is an argument against removal of these sub-therapeutic uses–if we can’t 100% guarantee it will help, why change the status quo?–but at this point, even the current status quo is better than an ever-increasing arc of resistant bacteria.

Another concern that persists and muddies the waters is that no meaningful reduction in antibiotic use in animals will occur, but that rather antibiotics used for growth promotion will just be repackaged as “prophylactic” use, which will still be allowed under the new guidance. The industry says this won’t happen, but without meaningful and transparent surveillance, how can we know if it is or not?

Additionally, other sources of low-level antibiotics may still be present on farms and in feed, such as the use of distiller’s grains in animal feed which may still contain some antibiotics. And even if antibiotics that are important for human medicine are removed altogether, resistance still may linger or even climb if we allow for other classes of antimicrobials (such as ionophores, which are part of that group I mentioned above that are used in agriculture but not in human medicine) to still be used on the farms. Why could this be an issue? Right now, we really don’t know if any of these drugs co-select for resistance to important human medicines. For example, in some cases, antibiotic resistance genes are together as cassettes that can move around between bugs, such as on a plasmid or other mobile genetic element. That’s why using tetracycline on a pig farm can select for methicillin resistance–not because the drugs are the same (they’re totally different classes), but because the resistance genes come as a package deal. Is this happening with ionophores? Don’t know. It’s a messy area and makes any clear-cut cause-and-effect research very difficult to carry out.

To make matters even messier, because there’s so much transport of animals across state, national, and international lines, even if antibiotics are reduced in one place, new resistant bugs could be imported from elsewhere where no reduction in antibiotic use has taken place, mucking up the data and making it appear that antibiotic withdrawal has had no effect.

Furthermore, there is no directive for companies to actually track and report antibiotic usage differences after growth-promotant antibiotics are removed. We can’t even get good data on the industry as a whole, much less finer-level data describing how much goes to pigs, how much to cattle, how much on Iowa pig farms versus North Carolina, or for Smithfield versus Hormel farms, etc. It’s a surveillance nightmare. Even if we did have this data, surveillance of resistant pathogens is quite limited, especially on the farms themselves. Most of the data we have comes from NARMS–the national antimicrobial resistance monitoring system, which examines gram negative pathogens in people, meat samples, and live animals (taken at slaughterhouses). It’s a start, but what if we don’t see an effects in these organisms–but might in other commensal pathogens, or in the microbiome as a whole? Or in gram positives like my pet bug, Staphylococcus aureus? NARMS right now would miss those, and so might lead to false impressions of how reduction in antibiotics is really affecting resistance in the bacteria originating on farms.

Soooo….as you can see, this is a messy area. However, as I noted on Twitter, one should look at the totality of the research rather than searching for any particular “smoking gun” publication (a fallacy, I might add, that is employed by many types of science “skeptics”). There have been many, many papers that have shown, usually in ecological studies, that use of antibiotics on the farm is linked to generation of resistant bacteria, and that these bacteria (and associated resistance genes) can spread to humans via food, water, environmental runoff/contamination, air, and other mechanisms. Pew Health has an extensive bibliography of many of these studies here, and it’s barely even scratching the surface when it comes to publications in this field. In the end, though it’s messy, it breaks down to a simple truth: antibiotic use leads to antibiotic resistance, and reduced use is a goal to strive for–be it use in humans or in animals.

Unpacking a bit more

Yesterday’s post was frustrating. However, if anything good came out of it, it was some sharing of stories and mutual affirmations on the Twitters that yes, this happens to women all too frequently; yes, it’s obnoxious; and that hopefully some people viewing it thought about their own internalized biases, and how those may reflect in behavior toward women. I’m reminded at times like these how important social media networks have been to me, both in introducing me to new people (I’ve already found many new scientists to follow because of this) and in having an outlet to discuss and commiserate. So, some thoughts.

1) I hadn’t considered this in the beginning (because it’s my life and all), but from the write-up alone, I probably sound like “just a mom,” especially with my baby’s picture within the post. I mention at one point my colleague and link to a fellow scientist, but let’s be honest–people don’t always read these posts carefully or all the way through. So I was an easy target. Many studies have shown that people still describe scientists as old, white men–the Einstein stereotype. Just google “scientist” and check out the images: a bunch of nerdy, older white guys for the most part, and a handful of women (some scantily dressed, cause that’s exactly how we science, amirite ladies?). I got this type of attitude just the other day, as the driver who picked me up at the Philadelphia airport (a driver who routinely transports scientists!) was still surprised that I was a young woman and doing the work that I do. I’ve gotten that response previously at conferences as well. Women just aren’t accepted as scientists, even at times by other people working in the field.

2) I think many people (especially men) may underestimate or not understand just how frustrating this type of behavior/attitude is to women. Or worse, minimize it or not accept that this happens. I’ve been gaslighted previously by male (and female!) colleagues, telling me that surely my perception of a situation or event was incorrect. I accepted that they were right at the time (this was long before #ripplesofdoubt or other such support and story-sharing). No way would I stand for that now.

3) Blowback. The current situation involved a pseudonymous man on the internet, but all too often in these types of situations where women are dismissed and their expertise minimized people are involved who are more difficult to ignore. They may be senior colleagues in one’s own department or college. People in the field who could be reviewers of your papers or grant applications. Even collaborators who, in theory, should respect your training and value your expertise can try to appropriate your work because they see themselves as more important. (Thankfully this has not happened to me, but it has to several of my female colleagues, with mixed results in the end as far as credit, authorship, etc.)

In the end, much of this type of sexism is not conscious on the part of the one initiating it. I’m sure that people who told me I don’t look like a scientist meant it as a compliment and truly believed it was–because after all, scientists aren’t supposed to be young, or female, or particularly attractive. I’m sure that those that may have assumed I’m “just a mom” and didn’t bother to pay any attention to my professional accomplishments before explaining my field to me don’t think they’re particularly biased against women. Outright, blatant bias against women is much tougher to get away with today (in theory, anyhow), but the more subtle, “everyday” sexist behaviors are still very much amongst us. If it hurts people’s feelings that they get called out on these, well, tough. The only way things change is by shedding light on them. I have a bright spotlight and I’m not afraid to use it.

Twitter-splained

Just wrapped up a meeting sponsored by the Center for Disease Dynamics, Economics, and Policy and Princeton University’s Department of Ecology and Evolutionary Biology and Environmental Institute on the topic of antibiotic resistance at the animal-human interface. While I was there, I hopped on Twitter at a break after mingling and pumping–and got my ass Twitter-splained. I should note that i have no idea who Doc Ricky is–or if said Doc is a man or a woman, but either gender can be susceptible to doubting the expertise of women and relying on men to “set them straight” as it appears happened here. Storify follows (link here).

The world’s foremost Proust scholar

The world’s foremost Proust scholar

Twitter-splained!

  1. Another article using “superbugs”  http://aetiologyblog.com/2014/05/13/superbugs-rising/  – and calling to action blaming antibiotic use on farms. #kneejerk
  2. @drricky That’s by @aetiology who has done her homework and may well know a lot more than you about this. Your hashtag may apply you.
  3. @SavorTooth Not going with the argument from authority fallacy. Article ends with a call to action that isn’t well thought out.
  4. @SavorTooth I have been looking at the data. Go past the false equivalence of the antibiotic classifications.
  5. @drricky Yeah, and she studies the data professionally at Iowa State. Hardly knee jerk.
  6. OK, so I know not everyone knows me or what I do. And my name is pretty common, so sometimes Google-fu is tough. Maybe linking to my website would help clear things up…
  7. .@SavorTooth @drricky Every post I write isn’t going 2 b science-heavy. Search my blog or pubs, plenty science there.  http://taracsmith.com 
  8. @aetiology @SavorTooth I call to question this particular post because it alludes to certain scientifically dubious premises.
  9. I also pointed out that even in the post, I don't put blame only on ag antibiotics. Even at the "Superbugs" meeting, we discussed human-use antibiotics. One of the speakers was Dan Uslan (@dan_uslan), an infectious disease doctor at UCLA. No one is dismissing this as a cause of resistance.
  10. @drricky I call in farms and clinics–note I described what docs/hospitals are doing. Any antibiotic use -> resistance.
  11. @aetiology @SavorTooth been combing pubmed for “smoking gun” articles for years.
  12. @aetiology yes – all antibiotics are of finite usage. But not all equivalent.
  13. @aetiology @SavorTooth Yes, indeed, I agree re: totality of evidence. But also indictment without sufficient evidence is unjust too.
  14. At this point, lunch at my meeting had ended and I went back to work–listening to other speakers talk about their work on antibiotic resistance. (My talk was yesterday). Meanwhile, all of these popped up:
  15. @aetiology @SavorTooth (btw – impt premise – I am going to keep this as academically neutral as possible) #discussionmode
  16. @aetiology consider the “call to action” ending of the article links to the pewtrusts advocacy. But it doesn’t detail what will be done.
  17. @aetiology @SavorTooth The WHO report doesn’t directly finger farm usage, but the pew trusts action pushes the 70% figure.
  18. @aetiology @SavorTooth The casual appearance of false equivalence in discussion antibiotics is problematic.
  19. @aetiology Abx resistance is a complex topic  http://mmbr.asm.org/content/74/3/417.full  impt to consider that resistance pbly evolved w the antibiotic
  20. @aetiology And the Davies review took care to define “superbug” in their paper  http://mmbr.asm.org/content/74/3/417.full  but this may not be the vernacular
  21. @aetiology @SavorTooth empiric antibiotic prescription in clinics as well as unsupervised used and disposal may be bigger problem.
  22. Obviously, he hadn't checked out my website!
  23. .@drricky @SavorTooth Are you really explaining antibiotic resistance to me?
  24. I didn't pull the "DO YOU KNOW WHO I AM?" card directly.
  25. .@drricky I’m currently at a small meeting @ Princeton w/ world’s experts on topic of antibiotic resistance. Guess what? I’m one of them.
  26. Willem van Schaik is another microbiologist (in the Netherlands). He affirmed that I know my shit.
  27. @aetiology @drricky I’ve read the blog-post and there is absolutely nothing wrong with it.
  28. @aetiology @drricky ‘possibly reducing antibiotic use on farms, though optimism is mixed regarding how much that will actually help things’
  29. @aetiology @drricky is a very fair assessment of the current situation
  30. There may have been some snark.
  31. @aetiology @drricky this is pretty funny, actually. Like explaining to LeBron what a jump shot is.
  32. Best mansplaining thread ever MT “@aetiology: @drricky I’m at a mtg w/ world’s experts on topic of abx resistance. Guess what? Im one of em”
  33. Apparently this affirmation appeased Doc Ricky, who earlier "was not going with the argument from authority fallacy." Guess it's different when the authority is a guy?
  34. @cmyeaton @chenghlee @aetiology @drricky always a good move to back down once a white dude shows up to back a woman up. #gross

Superbugs rising

It’s a parent’s worst nightmare. Your healthy child is suddenly ill. The doctors you’ve trusted to treat him are unable to do anything about it. Drugs that we’ve relied upon for decades are becoming increasingly useless as bacteria evolve resistance to them. New drugs are few and far between. Old drugs, shelved because of their toxic side-effects, are being brought in as last resorts–kidney failure, after all, is better than certain death.

Unfortunately, this is increasingly the state of medicine today, and people are dying from it. The World Health Organization even recently sounded the alarm, noting that “the world is headed for a post-antibiotic era”–and it takes a lot of consensus to get the WHO to act, so this is a Big Deal.

I was in Washington, DC last week for two days to discuss the issue with other “supermoms” and dads (farmers, physicians, researchers, and parents whose children had experienced antibiotic-resistant infections), and to share information with legislators and government agencies. (I also brought William, 4 months old, for an extra dose of adorableness).

Superbabies against Superbugs
Superbabies against Superbugs

Some of the “super” attendees might be familiar to readers. I had the pleasure of meeting Russ Kremer, who has been profiled in several articles and documentaries. Russ raised pigs in confinement, dosing them with antibiotics from birth to slaughter until he was gored by a boar, resulting in a very difficult-to-treat infection that almost cost him his life. David Ricci was also present. His story was profiled in the Frontline documentary, “Hunting the Nightmare Bacteria.” He contracted an infection with bacteria carrying the NDM-1 genes, making them resistant to almost all known antibiotics, and required multiple surgeries and treatment with some of these last-line drugs over many months.

There were also participants you may not have read about previously, like Amanda Hedin and Everly Marcario, who both lost children to antibiotic-resistant infections. I’ve written before about the immense sadness that comes at times when studying infectious disease, noting that I have a freezer full of bacterial isolates that, while important for study, frequently mark someone’s illness or death. It’s important work, but heart-wrenching at times.

However, we have very little funding to study such infections. My colleague Eli Perencevich recently estimated the amount of money spent on antibiotic-resistant infections versus HIV/AIDS, and the answer is that it’s vastly less. Antibiotic resistance needs to be a priority on many fronts. The FDA has recently made some headway into possibly reducing antibiotic use on farms, though optimism is mixed regarding how much that will actually help things. Hospitals and clinics are working with physicians to encourage and enforce best practices for antibiotic prescribing in these settings.

We need to be responsible with antibiotics. Drugs in development are scarce, and none are ready for prime time. It’s almost unimaginable that we may return to a time when an infected scrape could mean the death of a healthy young man, but we’re closing in on that every day. The WHO wrote in their report:

“A post-antibiotic era, in which common infections and minor injuries can kill, far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century.”

We need action, not promises. And we need it now.