Diego Rivera, the history of medicine in Mexico: peopled demand for better health, mural in 1953 still current / Diego Rivera: la historia de la medicina en México: el pueblo en demanda de salud, mural de 1953 aún vigente

Abstract: Although public health and social medicine have a long history in Latin America going back to Co lonial times, their relevance has ebbed and flowed as a result of the development of a variety of social and political movements. The Mexican Revolution accelerated implementation of public health po licies in Mexico and resulted in the creation of the Mexican Institute of Social Security to serve the health and social security needs of the country's population. Construction of the Hospital La Raza and its embellishment by the mural paintings of Diego Rivera and David Alfaro Siqueiros correspon ded to the heyday of public health ideas in Mexico. This is clearly reflected in Rivera's mural painting from 1953, The History of Medicine in Mexico: People's Demand for Better Health. The left side of the painting, representing the history of modern medicine in Mexico, exemplifies the tensions between individuals and social groups demanding the fruits of modern medicine and public health, and en trenched bureaucracy and private interests resisting their demands. Rivera's artistry illustrates this tension by depicting urban social groups and a family with a pregnant mother and children reques ting medical attention on one side of the main panel, facing condescending physicians, bureaucrats and upper society gentlemen and ladies on the other side. The importance of social movements to the development of public health policies illustrated by Rivera in 1953 continues to be relevant in Latin America today where increasing millions still lack the benefits of health care and social security.

El retablo de Isenheim: religión, arte y medicina / The Isenheim altarpiece: religion, art and medicine

Northern Europe at the beginning of the 16th Century was in turmoil as a result of religious and political dissention, epidemics of plague, syphilis, ergotism, and famine, and the threat of the Ottoman Empire. In Alsace, a fulcrum between Germany, France, Switzerland and the Netherlands, Grünewald painted his celebrated and complex altarpiece at Isenheim in a convent chapel of the Antonine religious order that kept a hospital for the care of patients suffering from ergotism, plague, syphilis and other illnesses. The ten paintings of this altarpiece convey a series of religious, medical and political meanings, with the scenes of the Crucifixion and the Resurrection being thought to play an integral part of the curative process. This was because patients could be soothed by comparing their suffering to that of Christ on the cross and could console themselves by the Resurrection. The portrait of Christ in the cross is astounding in its realism and naturalism. It represents, with great pathological veracity, a tortured body in agony, a break with previous traditional representations of this event. Impressive pathological detail is also given to a figure in the Temptation scene. The entire work is suffused with religious connotations provided by the composition, the forms and the richness and sophisticated use of colors. Although Grünewald's paintings are few and the facts of his personal life sparse, it is known he married a Jewish woman, supported the peasant revolts, and was probably a Lutheran in a Catholic area. While Grünewald is considered the epitome of a German artist, the universal projections of his art have influenced physicians and the artistic productions of many painters, writers, musicians and sculptors throughout the world.

Resistencia a los antimicrobianos en Chile y el paradigma de Una Salud: manejando los riesgos para la salud pública humana y animal resultante del uso de antimicrobianos en la acuicultura del salmón y en medicina / Antimicrobial resistance in Chile and The One Health paradigm: dealing with threats to human and veterinary health resulting from antimicrobial use in salmon aquaculture and the clinic

El aumento de la resistencia bacteriana múltiple a antimicrobianos es considerado una gran amenaza para la salud pública mundial y como generador de una importante crisis en el funcionamiento de los sistemas de salud. Esta crisis es discutida diariamente por los gobiernos y los parlamentos, las instituciones globales de salud, fundaciones benéficas y de científicos y de profesionales de la salud y también de consumidores de productos animales. En todos los países del orbe se ha identificado al uso de antimicrobianos en la crianza industrial de animales como un importante determinante en la selección de esta resistencia. Aprovechando la oportunidad que se ha planteado en Chile con el diseño del Plan Nacional Contra la Resistencia a los Antimicrobianos, hemos creído importante revisitar y actualizar sumariamente nuestros estudios sobre el uso de antimicrobianos en la acuicultura del salmón y de su potencial impacto en el ambiente y la salud humana y animal. Estos estudios indican que 95% de tres grupos de antimicrobianos importados al país, que incluyen tetraciclinas, fenicoles y quinolonas, son usados en medicina veterinaria y mayormente en la acuicultura del salmón. Nuestros estudios indican que el excesivo uso de estos antimicrobianos genera la presencia de residuos de antimicrobianos en el ambiente marino hasta 8 km de los sitios de acuicultura, los que seleccionan a bacterias con resistencia múltiple en dicho ambiente, ya que ellas contienen variados genes de resistencia a estos antimicrobianos. Estos genes de resistencia están contenidos en elementos genéticos móviles incluyendo plásmidos e integrones, los que son trasmitidos a otras bacterias permitiendo su potencial diseminación epidémica entre poblaciones bacterianas. Bacterias del ambiente marino contienen genes idénticos a los genes de resistencia a quinolonas e integrones similares a los de patógenos humanos, sugiriendo comunicación genética entre estas bacterias de diversos ambientes. Alrededor de los recintos de acuicultura, este uso exagerado de antimicrobianos contamina con ellos también a peces silvestres para consumo humano y potencialmente selecciona BRA en su carne y en los productos de acuicultura. El consumo de estos productos selecciona bacterias resistentes en el microbioma humano y facilita también el intercambio genético entre bacterias del ambiente acuático y la microbiota comensal y patógena humana. El pasaje de antimicrobianos al ambiente marino disminuye la diversidad en él, y potencialmente podría facilitar la aparición de florecimientos de algas nocivas, la infección de peces por patógenos piscícolas resistentes los antimicrobianos y la aparición de patógenos zoonóticos resistentes, incluyendo a Vibrio parahaemolyticus. Estos hallazgos sugieren que la prevención de infecciones en peces y la disminución del uso de antimicrobianos en su crianza, será en Chile un factor determinante en la prevención de infecciones humanas y animales con resistencia múltiple a los antimicrobianos, de acuerdo con el paradigma moderno e integral de Una Salud.

The emergence and dissemination of antimicrobial-resistant bacteria (ARB) is currently seen as one of the major threats to human and animal public health. Veterinary use of antimicrobials in both developing and developed countries is many-fold greater than their use in human medicine and is an important determinant in selection of ARB. In light of the recently outlined National Plan Against Antimicrobial Resistance in Chile, our findings on antimicrobial use in salmon aquaculture and their impact on the environment and human health are highly relevant. Ninety-five percent of tetracyclines, phenicols and quinolones imported into Chile between 1998 and 2015 were for veterinary use, mostly in salmon aquaculture. Excessive use of antimicrobials at aquaculture sites was associated with antimicrobial residues in marine sediments 8 km distant and the presence of resistant marine bacteria harboring easily transmissible resistance genes, in mobile genetic elements, to these same antimicrobials. Moreover, quinolone and integron resistance genes in human pathogens isolated from patients in coastal regions adjacent to aquaculture sites were identical to genes isolated from regional marine bacteria, consistent with genetic communication between bacteria in these different environments. Passage of antimicrobials into the marine environment can potentially diminish environmental diversity, contaminate wild fish for human consumption, and facilitate the appearance of harmful algal blooms and resistant zoonotic and human pathogens. Our findings suggest that changes in aquaculture in Chile that prevent fish infections and decrease antimicrobial usage will prove a determining factor in preventing human and animal infections with multiply-resistant ARB in accord with the modern paradigm of One Health.

Epidemia de Clostridium difficile, Chile 2012: Informe de la Sociedad Chilena de Infectología. Una aproximación científico histórica / Clostridium difficile epidemic, Chile 2012: Report of the Chilean Society for Infectious Diseases. A scientific historical analysis

A Summary Report from the Chilean Society for Infectious Diseases regarding the presence of a Clostridium difficile epidemic with several fatalities in Chile's premier emergency public hospital in Santiago is used to make a scientific historical analysis of the situation. This Summary Report identifies several hygienic and sanitary shortcomings that may have played a role in triggering this major epidemic. These include deficiencies in hand washing policies, overcrowding of beds in wards, relaxation of infection control policies, antimicrobial therapy mismanagement and lack of laboratory support. The relevance of these shortcomings to the epidemic is further supported by the lack of any laboratory evidence for the presence of hypertoxigenic strains of C. difficile. In an era of whole genome sequencing of pathogens to guide therapy, prevention, and epidemiological studies of infectious diseases, it is illuminating and sobering, as this report so clearly demonstrates, to realize that many epidemics of hospital infections still result from breakdowns in classical and ancillary asepsis and infection control measures developed in the nineteenth century by Semmelweis, Nightingale and Lister. As the Summary Report suggests, such hygienic breakdowns in countries like Chile are usually brought about by lack of implementation and regulation of national hospital infection control policies resulting from the shift of economic resources from the public to the private sector, despite the former being responsible for health care of 80% of the population.

Medicina, música, amistad y prejuicios: Billroth I y Billroth II, los cuartetos para cuerdas Opus 51, N° 1 y N° 2 de Johannes Brahms / Medicine, music, friendship and prejudices: Billroth I and Billroth II, the string quartets Opus 51, N° 1 and N° 2 by Johannes Brahms

Background: The great German surgeon Theodor Billroth and the imaginative and creative composer Johannes Brahms had a very close friendship centered on musical activities, that lasted for more than thirty years while they lived and worked in Zurich and Vienna, during the second half of the Nineteenth Century. Billroth, besides his all-consuming medical activities, had time to be a musical enthusiast who directed orchestras, played the violin in chamber music groups, and wrote musical criticism for newspapers. The common affection between these two creative giants is documented by their abundant and effusive correspondence, by the constant requests by Brahms of Billroth's opinions regarding his compositions, and by the positive and stimulating answers that Billroth gave to these requests. Billroth opened his house for musical evenings to play Brahms chamber compositions for the first time, and Brahms dedicated his two Opus 51 string quartets Nos. 1 and 2, known in the musical milieu as Billroth I and II, to his physician friend. Unfortunately, the close bonds between these two geniuses weakened towards the end of their lives as a result of Billroth's becoming intolerant to the lack of social refinements and gruff behavior of the composer. This baffling intolerance of Billroth to his friend Brahms can be better understood after reading Billroth's writings in his book The Medical Sciences in the German Universities. A Study in the History of Civilization. There Billroth expresses strong prejudices against potential medical students of humble social origins, such as those of Brahms, coupled to a primitive anti-Semitism.

Uso inadecuado y excesivo de antibióticos: Salud pública y salmonicultura en Chile / Injudicious and excessive use of antibiotics: Public health and salmon aquaculture in Chile

Salmón aquaculture was one ofthe major growing and exporting industries in Chile. Its development was accompanied by an increasing and excessive use oflarge amounts of antimicrobials, such as quinolones, tetracyclines and florfenicol. The examination of the sanitary conditions in the industry as part of a more general investigation into the uncontrolled and extensive dissemination of the ISA virus epizootic in 2008, found numerous and wide-ranging shortcomings and limitations in management of preventive fish health. There was a growing industrial use of large amounts of antimicrobials as an attempt at prophylaxis of bacterial infections resulting from widespread unsanitary and unhealthy fish rearing conditions. As might be expected, these attempts were unsuccessful and this heavy antimicrobial use failed to prevent viral and parasitic epizootics. Comparative analysis of the amounts of antimicrobials, especially quinolones, consumed in salmón aquaculture and in human medicine in Chile robustly suggests that the most important selective pressurefor antibiotic resistant bacteria in the country will be excessive antibiotic use in this industry. This excessive use will facilitate selection of resistant bacteria and resistance genes in water environments. The commonality of antibiotic resistance genes and the mobilome between environmental aquatic bacteria, fishpathogens and pathogens of terrestrial animáis and humans suggests that horizontal gene transfer occurs between the resistome of these apparently independent and isolated bacterial populations. Thus, excessive antibiotic use in the marine environment in aquaculture is not innocuous and can potentially negatively affect therapy of bacterial infections of humans and terrestrial animáis.

El Dr. Guillermo Contreras Da Silva, una figura señera en la microbiología y la salud pública chilena / Dr Guillermo Contreras Da Silva, a relevant figure in the development of Chilean microbiology

The influence of the work of Dr. Guillermo Contreras Da Silva and his colaborators on the evolution of microbiology in Chile is briefly analyzed. Dr. Contreras was trained in modern virology at Yale University with Dr. J. Melnick under the sponsorhip of the Rockefeller Foundation. During this training, he used serological methods to classify Cocksakie viruses. After his return to Chile, he studied the epidemiology of enteroviruses, including poliovirus. His laboratory, the country's first in modern virology, took an active role in Chile's first Sabin polio vaccination in 1961. Dr. Contreras and his group transformed the teaching and the character of microbiology in Chile from a descriptive medically oriented discipline into an autonomous, quantitative and experimental science. They modernized microbiology with the introduction of molecular biology and microbial genetics and fostered collaborations with allied biological sciences. Dr. Contreras was a Guggenheim Fellow, and until his retirement, was the Chief of the Viral Products Division, Bureau of Biologies, Ottawa, Canada.

Acuicultura y salud pública: La expansión de la difilobotriasis en Chile y el mundo / Aquaculture and public health: The emergence of diphyllobothriasis in Chileand the world

Recent clinical and epidemiológica! information, an analysis of the literature, and study of the technical aspects of Chilean salmon aquaculture indicate that this activity has the ability to expand the range of diphyllobothriasis caused by the fish tapeworm Diphyllobothrium latum. Evidence for expansion of the range of the fish tapeworm includes the emergences of clinical cases in Brazil related to consumption of salmon produced in Chile. Expansion of the range of this parasite is also suggested by an increase of its geographical range in Chile, beyond its previously endemic foci in the lakes of Regions IX and X. Prevention of further dissemination of this parasitic disease rests on an improvement of sanitation and sewage disposal around the lakes of Regions IX, X and XI in Chile, improvement in aquaculture methods including curtailing the use offish tapeworm-contaminated lakes to grow juveniles forms ofsalmonids and more measures to decrease the number of salmonid escapees from marine pens to prevent their return to rivers and lakes carrying the infestation. Moreover, tracking the origin ofjuveniies in marketed salmon, determining the presence of plerocercoids in them, and increased education of the public regarding the potential dangers of eating raw fish should also be implemented. Only by stimulating the dialogue between the industry, consumers and state regulators will it be possible to implement appropriate measures to prevent further expansion of this parasitic disease by salmon aquaculture.

Antibióticos y acuicultura en Chile: consecuencias para la salud humana y animal / Antibiotics and aquaculture in Chile: Implications for human and animal health

Industrial antibiotic usage in agribusinesses and aquaculture is the force that drives the evolution of antibiotic resistant bacteria that produce human and animal disease in many countries. Several studies have demonstrated that most of the industrial use of antibiotics is unnecessary, and that modernization and hygienic changes can reduce this use of antibiotics without negative economic impact. In Chile, industrial aquaculture of salmon has expanded rapidly in the last 20 years becoming a major export business. The exponential growth of this industry has been accompanied by an unrestricted heavy usage of antibiotics in the aquatic environments of lakes, rivers and the ocean, and its impact is being felt in the emergence of antibiotic-resistant bacteria around aquaculture sites and a decrease in the plancktonic diversity in the same areas. The passage of antibiotic resistance genes from aquatic bacteria to human and animal pathogens has been demonstrated, indicating that industrial use of antibiotics in aquaculture affects negatively the antibiotic therapy of human and animal bacterial infections. The Chilean situation triggers important concerns because it includes the use of fluoroquinolones in aquaculture, that are not biodegradable and are able to remain in the environment for years as well as being still effective in treating human infections. The use of large volumes of a wide spectrum of antibiotics in an aquatic environment heavily contaminated with human and animal pathogens also amplifies the opportunities for gene transfer among bacteria, facilitating the emergence of antibiotic resistance and more pathogenic bacterial recombinants. The detection of residual antibiotics in salmons marketed for human consumption that can modify the normal flora of the population also suggests the need for controls on this antibiotic usage and on the presence of residual antibiotics in aquaculture food products. This important problem of public health demands an active dialogue between government officials responsible for protecting public health, aquaculture industry representatives, politicians, consumers and professionals dealing with these matters (Rev Méd Chile 2004; 132: 1001-6).

Evolutionary control of infectious disease: prospects for vectorborne and waterborne pathogens

Evolutionary theory may contribute to practical solutions for control of disease by identifying interventions that may cause pathogens to evolve to reduce virulence. Theory predicts, for example, that pathogens transmitted by water or arthropod vectors should evolve to relatively high levels of virulence because such pathogens can gain the evolutionary benefits of relatively high levels of host exploitation while paying little price from host illness. The entrance of Vibrio cholerae into South America in 1991 has generated a natural experiment that allows testing of this idea by determining whether geographic and temporal variations in toxigenicity correspond to variation in the potencial for waterborne transmission. Preliminary studies show such correspondences: toxigenicity is negatively associated with access to uncontaminated water in Brazil; and in Chile, where the potential for waterborne transmission is particularly low, toxigenicity of strains declined between 1991 and 1998. In theory vector-proofing of houses should be similarly associated with benignity of vectorborne pathogens, such as the agents of dengue, malaria, and Chagas'disease. These preliminary studies draw attention to the need for definitive prospective experiments to determine whether interventions such as provisioning of uncontaminated water and vector -proofing of houses cause evolutionary reductions in virulence.