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This introductory chapter describes the increasing prevalence of hospital-acquired infections (HAIs) plaguing hospitals across the United States, Canada, and Europe. It outlines the dangers of hospital infections and the tolls this takes on both patients and hospitals alike. Though steps have been taken to minimize the risk of infection in hospital environments and to promote hospital cleanliness, the problem perseveres. There are many complex factors that contribute to this problem, though this chapter focuses on the rise of outsourcing as one possible cause. The chapter delves into an in-depth study of the consequences of outsourcing in hospitals, for both the patients and the outsourced hospital workers—who are themselves victims in a larger trend of franchise capitalism.

This concluding chapter suggests measures for hospitals to reduce infection, as well as provide better economic opportunities for the working poor. Countries such as the Netherlands and Norway have done an extraordinary job of keeping rates of hospital-acquired infections extremely low. They have been proactive about hospital hygiene and other infection-control approaches and have largely avoided outsourcing hospital support services. From their example the chapter argues that focusing on preventive health care and public welfare are far more efficient ways of obtaining better health outcomes. Moreover, better health care is also dependent on the well-being of health support staff—in short, a new movement dedicated to fighting germs must also, on a fundamental level, uplift its workers.

Bacteria evolve resistance to antibiotics with near certainty after several years of widespread use. Resistance can evolve via several genetic mechanisms and spread through and between species via gene transfer. Resistance that evolves in agricultural settings can transfer into human populations. Associations among resistance genes, and the process of compensatory evolution, can cause retention of resistance genes, even in the absence of selection favoring resistance. Novel approaches to antimicrobial therapy may provide alternatives to traditional broad-spectrum antibiotics for which resistance is less quick to evolve. To eradicate antibiotic resistance from a hospital setting, researchers need a thorough understanding of the underlying ecology. For example, antibiotic cycling, the hospital equivalent of crop rotation, does not necessarily reduce the environmental heterogeneity at the scale relevant to bacterial clones spreading through the hospital and thus may be ineffective at reducing the frequency of resistant strains in a hospital setting.

An evolutionary suggests that health interventions can reduce not only the frequency of infectious disease but also the harmfulness of the causal organisms. Interventions that may accomplish this dual goal include hygienic investments such as vector proofing of housing, provisioning of safe water supplies, infrastructure that blocks transmission of durable propagules, the prevention of attendant-borne transmission in hospitals and reductions in the potential for sexual transmission. Vaccines can also reduce the frequency of infection and the harmfulness of the target organisms if they are designed to inhibit selectively the harmful variants in the target population. These approaches should help suppress the evolution of antimicrobial resistance because benign variants causing mild or asymptomatic infections will be less exposed to antimicrobial treatment, reducing the strength of selection for antimicrobial resistance. The interventions should improve health at low cost, which would be especially important for low-income populations.

Unbridled optimism and a flurry of organizational activity followed the publication of To Err is Human. As patient safety became corporatized into new institutions and programs; it became mainstreamed and adopted by organized healthcare. Patient safety became dominated by a measure and manage approach. US hospitals added patient safety to existing quality, risk management and regulatory compliance bureaucracy. This internalization and incorporation led to a closing off of patient safety from influences outside of healthcare. Infection control and health information technology began to dominate safety efforts. Safety culture became a popular topic but in a narrow and instrumental way.