nature

The basic story on which all appear to agree is that at least 50 people in the intensive care unit of the Social Security Fund (CSS) flagship hospital, the Arnulfo Arias Hospital Complex that's adjacent to the University of Panama, were infected with a drug-resistant strain of Klebsiella pneumoniae and that at least 16 of those who were infected died. These bacteria are "Gram-negative" --- that is, they do not retain crystal violet dye in the Gram staining protocol, which indicates certain properties of their cell walls, particularly the lipopolysaccharide (LPS) layer that triggers immune responses. These properties make such bacteria immune to many antibiotics in the best of circumstances, but Gram-negative bacteria also more readily swap genes with other microbes than do Gram-positive bacteria, which tend to create fast-mutating "moving targets" over the course of a disease outbreak. Of particular concern is when they acquire genes for extended spectrum beta-lactamases (ESBLs), which render them immune to many antibiotics.

There are at least two strains of drug resistant Klebsiella pneumoniae going around in the world. In July of 2010 the Pan-American Health Organization reported an outbreak of one of these strains in Argentina and some cases in other Latin American countries. This year there have been drug resistant Klebsiella pneumoniae outbreaks in several European countries, with a death rate of about 40 percent of those infected. There are a few antibiotics that can be used, and sometimes palliative care will save the patient as the infection runs its course. Sometimes the infections can be so bad that surgery is required to remove dead tissues, for example parts of the intestinal tract in an abdominal infection. The important things when there is an outbreak of drug resistant Klebsiella pneumoniae in a hospital is to isolate the patient and disinfect all areas where the patient has been. Because this can take the form of a contagious respiratory infection, it can get into ventilating systems and spread throughout a hospital that way, which can turn disinfection into a herculean task.

The public first heard about this outbreak not from the mainstream media but from the labor movement, with FRENADESO Noticias reporting on June 20th that a particularly deadly strain of bacteria was going around on several floors of the main CSS hospital complex and that people had died. Over the following days AMOACSS (the CSS doctors' association) and COMENENAL (the alliance and joint bargaining committee of physicians' organizations whose members work in the public health care system --- the CSS and the Ministry of Health hospitals and clinics, and the various hybrid facilities set up under government-controlled but ostensibly private foundations), weighed in with cautious statements about the situation. The CSS employees' caution derived in part from a June 13 edict from director Guillermo Sáez Llorens threatening to fire any CSS employee who talks to the press or anyone else outside of the institution about any matter affecting the CSS.

Political warfare between public health care system employees and managements? That's the norm, and certainly nothing new for President Martinelli. However, as the dates and details of this particular problem began to emerge, it began to appear that the Sáez Llorens gag order was not a random generic bit of labor bashing by an anti-union administration, but part of a desperate information control effort related to the Klebsiella pneumoniae outbreak. From CSS and Ministry of Health management statements, the pronouncements of organized labor and reports in both the mainstream and the left press (including pro-Martinelli media), there has emerged a timeline that goes something like this:

• June 2010: the Pan-American Health Organization (PAHO) reports drug-resistant Klebsiella pneumoniae in Argentina.

• July 2010: PAHO notes outbreaks elsewhere in Latin America, warns that the resistant bacteria are causing a mortality rate of between 47 and 68 percent, acknowledges that with emerging strains there is uncertainty about how to treat infections, and recommends:
  a) the isolation of infected patients
  b) disinfection of hospital environments where the bacteria are encountered using chlorine bleach
  c) enhanced vigilance for and reporting of infections
  d) widespread dissemination of alerts in the case of outbreaks so as to protect health care workers and to allow people to make informed health care decisions.

• August 2010: Two different strains of the drug-resistant Klebsiella pneumoniae bacteria are identified at the Arnulfo Arias Hospital Complex.

• December 15, 2010: The Ministry of Health is notified of the detection of these bacteria four months earlier.

• December 27, 2010: The Ministry of Health issues a bulletin about vigilance and reporting of Klebsiella pneumoniae.

• December 28, 2010: The Ministry of Health asks CSS director Sáez Llorens for a detailed report on the Klebsiella pneumoniae at the hospital complex. Sáez Llorens ignores this request.

• May, 2011: Several cases of Klebsiella pneumoniae infection are encountered at the hospital complex.

• June 3, 2011: At a seminar put on by the National Hospital Infection Committee the results of new lab tests finding drug resistant Klebsiella pneumoniae at the hospital complex are noted. The Ministry of Health schedules a hospital visit.

• June 9, 2011: The Ministry of Health requests a report on the outbreak from the CSS hospital infection coordinator, José Luis Moreno.

• June 12, 2011: The Ministry of Health issues a second bulletin to CSS, specifically about vigilance for and reporting of Klebsiella pneumoniae infections.

• June 13, 2011: CSS director Saéz Llorens issues his gag order.

• June 20, 2011: FRENADESO Noticias breaks the story that there is an outbreak of drug resistant bacteria at the hospital complex.

• June 21, 2011: The CSS board of directors visits the hospital complex, and they are told that the problem is under control.

• June 22, 2011: José Luis Moreno submits his report to the Ministry of Health about the Klebsiella pneumoniae outbreak, which apparently contradicts some of the assurances given to the CSS board the previous day. A few days later, he is fired.

• July 28, 2011: The CSS admits that there was an outbreak of drug resistant Klebsiella pneumoniae infections at the hospital complex and says that it affected 51 patients, 16 of whom died. Various doctors at the complex say that these figures understate the numbers of infections and deaths, and COMENENAL estimates that the actual death toll is probably around 50.

• July 29, 2011: The CSS issues a statement on its website claiming that the problem is confined to the intensive care unit and announcing that the areas of the hospital that it says are affected will be cleaned on August 12. There is widespread criticism in the medical community of the notion that the pathogens would not have spread beyond the intensive care unit.

• July 29, 2011: Responding to complaints by labor unions and relatives of some of those who became infected and died, the Public Ministry opened a criminal investigation of the handling of the drug resistant bacteria outbreak, looking into whether any deaths could be attributed to criminal negligence. There was a rising chorus of calls for the removal of Saéz Llorens as CSS director.

• August 1, 2011: Breaking with the CSS defense of its actions and plans for the future, Minister of the Presidency Jimmy Papadimitriu advocates the temporary evacuation of the hospital complex so that it can be thoroughly cleaned.

Not the first such scandal

The Martinelli administration's defensive reaction to this problem at the hospital complex is colored by the president's long years of hostility to CSS employee unions. He was CSS director during the Pérez Balladares administration and his tenure was marked by battles with the unions. They all came to a head when 11 kidney patients died during or shortly after dialysis. The chemical containers from the machines all disappeared before investigators could inspect them, a wall of silence went up and the cause of the deaths was never officially established. Most probably some bad --- possibly expired or possibly improperly stored --- dialysis chemicals were used. Former First Lady Ana Mae Díz de Endara proclaimed that the basic cause of death was Martinelli's mismanagement, which prompted Martinelli to bring a criminal defamation charge against her. Former President Guillermo Endara came to his wife's defense and made some bigoted and apparently untrue remarks about Martinelli's sexual orientation, and Martinelli charged him with criminal defamation for that. In the end, Mrs. Endara was acquitted and Mr. Endara was convicted but quickly pardoned by Mireya Moscoso. However, long before those legal cases ran their courses Toro asked for Martinelli's resignation and it has been a cause of bitterness between Martinelli and both Pérez Balladares and the CSS unions ever since.

During the Moscoso administration, at least 28 patients received radiation overdoses while being treated for cancer on a machine at the Instituto Oncologico Nacional. A bunch of health care professionals were blamed and received penalties ranging from license suspensions to a prison term. However, the US-designed software for that machine was faulty, and the hospital had no operator's manual for the machine. The case was aggravated when, apparently from a group of international investigators, La Prensa obtained the medical records of the overdose victims and published them.

During the Torrijos administration a politically connected importer who had the contract to supply chemicals to the now defunct CSS medicine production lab bought what it thought was glycerin from a Spanish wholesaler. Some of the jugs of that lot actually contained toxic diethylene glycol (DEG), which had been labeled by its Chinese manufacturer, in Chinese, as "substitute" glycerin. The chemicals made their way through a Chinese exporter, a Spanish wholesaler and the Panamanian importer, with the labels getting changed at least twice before coming to the CSS lab, where the DEG was mixed into cough syrup. Although the official death toll is much lower, hundreds died and many more were made seriously ill. At least three of the patients who died from the Klebsiella pneumoniae infections were being treated for the toxic effects of tainted cough syrup that they ingested in 2006. In order to minimize government spending and personal political blame, the Torrijos administration cut off funds for the toxicology tests on the remains of those who were thought to have died from DEG poisoning, and those who claimed that they were sick from this cause. After a short while DEG degrades and it becomes impossible to positively identify in either living or dead tissues. President Torrijos took the position that without an absolutely positive toxicology report, a poisoning didn't happen. When a crowd of sick people descended on the Presidencia to protest, the SPI presidential guards beat them up. The most serious aggravating factor, which has never been the subject of any official investigation, was that in July of 2006 the CSS and Ministry of Health managements were told by health care workers that there was a problem with mysterious sudden deaths and illnesses, but this information was suppressed and not acted upon until late September of that year, leading to many more deaths than if the matter had been dealt with promptly and transparently. There are still ongoing criminal cases from that incident.