While I’m loath to disagree with Maryn McKenna (aka Scary Disease Lady), I think both she and Ramanan Laxminarayan are overthinking the correlation between regions in the U.S. with poor health (high rates of diabetes, stroke, and obesity) and antibiotic use. Laxminarayan:

I asked Ramanan Laxminarayan, the director of Extending the Cure, what he thought was going on behind this unexpected concordance. He suggested that the antibiotic use might be an effect of poor health status, in that people who have many things wrong with them may go to the doctor more, and may obtain antibiotics — perhaps inappropriately — while they are there. (He is the lead author in research showing a higher rate of antibiotic use during flu season, even though flu is a viral disease which antibiotics cannot affect.)

I think this is partly correct, at least in terms of medical visits (I’ll get to that in a bit). McKenna goes further (boldface mine):

It is not new news that West Virginia, Kentucky and Alabama — and to a lesser extent, Tennessee, Georgia and Mississippi — are seriously unhealthy places. They are notoriously among the poorest states in the US, and with poverty comes the worst access to health care and the greatest incidence of lifestyle diseases.

However, lack of access to health care doesn’t, to me, correlate with higher-than usual amounts of antibiotic use. That doesn’t make sense organizationally or economically; if you can’t access health care, where are you getting the prescriptions from? It doesn’t make sense behaviorally, either. Obesity, diabetes, and cardiovascular disease are health-ignoring behaviors; they are among the things that happen when you don’t take care of yourself. But taking antibiotics is, at least on its face, a health-seeking behavior — after all, to obtain a prescription you must visit a health professional….

On the other hand, what if antibiotics cause these other health effects? That lines up with the work of Martin Blaser of New York University, who has proposed that taking antibiotics permanently kills off beneficial bacteria in the gut — and might therefore be responsible for changes in nutrient absorption and for the rise in obesity and diabetes.

In fairness, McKenna admits that the microbiome hypothesis is speculation. But I think there’s something more mundane, yet tragic, going on here.

The obesity-related diseases–and let’s add smoking and kidney failure to the mix, since those are more frequent in these states too–will lead to increased hospitalization. For many people who have limited access to the healthcare system, the only access they do have is emergency room care. But emergency room care, such as dealing with a heart attack or a stroke, is extremely invasive: it can require catheterization and intubation (being placed on a ventilator). This places the patient at higher risk for infection. Add to that the effect of obesity on hospital-acquired infections, and we would expect more antibiotic use (including preventative use). In addition, obese patients with multiple issues (e.g., smoking) are overall less healthy and will be under severe stress (or more severe stress) and thus more susceptible to infection and less likely to fight off infections on their own.

If we also include other diseases such as kidney-related diseases, treatment also requires invasive procedures. Diabetes is also another issue: there is a whole subgenre of the infectious disease microbiological literature that is dedicated to ulcers, often on the feet, in people with adult-onset diabetes. These ulcers often require antibiotic therapy.

Put simply, the diseases McKenna cites, along with a couple others, are diseases exacerbated by neglect*. However, we typically don’t let people die–they tend to get medical treatment, albeit not preventative treatment, such as catching diabetes when it starts. So these at-risk patients wind up with serious healthcare problems for which antibiotics are used (surgery) or have developed chronic conditions that increase the possibility of bacterial infection.

For patients who are trending towards multiple illnesses, preventative medicine can help them immensely. And by doing so, they would be less likely to have to use antibiotics. Not very sexy, but still very important.

*I’m not casting blame here: the neglect is often due to the inability to afford regular healthcare. Nonetheless, it is neglect, albeit often involuntary.