ICU and You · Podcast Sessions · Number 58
The disease is the easy part. Tex Kissoon on everything around it
A joint WFPICCS and PCICS production, free to listen to. One long argument rather than a medley, so it wants an uninterrupted drive or a long walk rather than the gaps between cases.
Listen first. It is not a test. Do not take notes, do not try to hold the numbers, and do not stop to look anything up. Let it wash over you on a drive or a walk and accept that most of it will not stick. That is not a failure of attention; it is how listening works.
What a podcast does that no paper can is let you hear somebody think. The hesitations, the qualifications, the places where an expert says plainly that we do not know — none of that survives into print, and it is most of what you are actually there for. You are picking up how somebody holds a problem, not a set of facts.
Then talk about it. Bring one thing to a ward round, argue with somebody about it over coffee, disagree with the guest out loud. An episode discussed once is worth three listened to alone.
And if something matters enough to act on, look it up properly afterwards. A podcast is a way in, not a source.
World Sepsis Day fell on 13 September, two days before this fortnight went up. This episode was recorded for it — and the day itself, as you will hear, is one of the things Tex Kissoon built.
A word about why this sits in a fortnight on the school-age child. Sepsis is one of the few things that does not much care how old you are — it is on this fortnight's map, it was on the last one, and it will be on the next. But there is a sharper reason for putting this episode here. The school-age block is where our clinical material is at its most technical: pulse pressures, fluid quotas, antidote regimens, the fourth power of a radius. This is the episode that points out none of that is where most of the world's children are dying.
Almost everything we write about sepsis is about the first hour. Recognise it, take cultures, give antibiotics, give fluid, escalate. That is the part intensive care is good at and the part our guidelines cover.
This is about the other ninety-nine per cent. Kissoon is professor of paediatrics, critical care and emergency medicine at the University of British Columbia, a founder and now president of the Global Sepsis Alliance, past president of the World Federation of Pediatric Intensive and Critical Care Societies, and co-chair of the last two paediatric Surviving Sepsis Campaign guidelines. He is speaking ahead of the WFPICCS congress in Melbourne.
His argument is that sepsis is not one kind of problem. It is three, and only one of them is ours.
The part we recognise. A patient becomes infected, develops organ dysfunction, and we treat it. This is the whole of sepsis as most of us were taught it, and Kissoon does not dispute any of it. He simply declines to stop there.
Because government decisions change who gets it and who survives. His example is the one nobody in a wealthy country enjoys: at the height of COVID, when the rich countries had bought the vaccine supply, something like 85 per cent of Canadians were vaccinated against roughly 15 per cent across Africa. He adds a second, closer to home: rich countries recruit their staff out of poor ones, and know they are doing it. A disease of inequity, in his phrase, and inequity is made by decisions.
It concentrates in the poor and disadvantaged, and it does so inside wealthy countries as well as between them. Malnutrition is a contributing factor in about half of children who die of sepsis, with HIV and tuberculosis behind that. Of the seventeen Sustainable Development Goals, he counts roughly eight that bear directly on sepsis — hunger, water, gender equity, resilient health systems, affordable medicines.
Asked what clinicians in well-resourced units are missing, he gives a phrase he has used in print: look beyond the double doors.
Every child who arrives in your unit with sepsis arrived by a route, and the route has features you could see if you looked. His examples are deliberately ordinary. Road trauma fell because the public demanded seatbelt and speed laws, not because intensive care improved. Vaccine hesitancy is now generating admissions. Food insecurity is high and invisible from inside a hospital. And the deficits he meets in sub-Saharan Africa — no access, no down-referral, no public health infrastructure — he says he recognises in impoverished communities in the United States and Canada.
His conclusion is uncomfortable and worth sitting with: intensive care does the visible, technical, satisfying part of the work, and we are not the people who will fix the antecedents. But we are the people who can see them, and we have standing to say so.
He borrows a line from a Harvard global health colleague: borders behave like semi-permeable membranes. Infections and sepsis pass freely; policy, money and cures do not. Antimicrobial resistance makes the point concrete — with hundreds of thousands of flights in the air, a resistant organism is one flight from anywhere. The Lancet Commission position he cites is that if current trends continue we lose the antibiotics that make complex cancer care, transplantation and cardiac surgery possible at all.
Sepsis is, he says, the leading killer of children worldwide. Eighty-five per cent of both the burden and the deaths fall in low- and middle-income countries — and the reason so many of those deaths are children is demographic as much as clinical: in many African and Asian countries the median age of the population is under sixteen.
He cites the 2020 Lancet Global Burden of Disease analysis at roughly 50 million cases and 11 million deaths a year, sepsis implicated in one death in five. A more recent paper puts it far higher — he quotes 166 million cases, 21 million deaths, and sepsis implicated in one death in three. He also notes that about half of sepsis deaths are complicated by non-communicable disease, so the familiar argument about whether to fund communicable or non-communicable disease is, in his words, not an either-or.
Both of those figures are all-age, whole-population estimates. They are not childhood figures, and they are quoted in circulation as though they were often enough that it is worth saying so plainly here.
The paediatric numbers, from a 2024 review in Lancet Child & Adolescent Health on which Kissoon is a co-author, are approximately 25 million sepsis cases a year across neonatal and paediatric age groups, and around 3 million deaths — with the same eighty-five per cent falling in low- and middle-income countries.
And the leap from 11 million deaths to 21 million is mostly not a real-world tripling of disease. The later analysis widened the case definition to capture infections recorded without an explicit sepsis code, so a large part of the increase is a change in what is being counted. Both numbers are defensible; putting them side by side without that explanation is not.
This is the section to listen to if you listen to nothing else, and it is the one most relevant to a unit like ours.
Acute care treats sepsis, the patient improves, and we stop thinking about them. Kissoon's figures: around 40 per cent are readmitted, and many die within a year of discharge. Work done over decades in South Africa found that as many children die within six months of leaving hospital as die in it — and that 70 to 80 per cent of those never make it back to care. They die at home.
At the World Congress of Intensive Care he sat in a session with people who had survived sepsis. Two women said the same thing: their problems did not begin when they became septic. They began after discharge.
One had lost her job, then her house because she could not pay for it, and ten years of her reproductive life. The other had lost her job and now has chronic renal failure, is dialysed, depends on other people to get her there, and may need a transplant.
None of that appears in a mortality figure, and none of it is what we audit.
The most striking passage, and the least clinical. A large study of educational attainment found that where a mother had completed around eight years of schooling, her under-fives were roughly 31 per cent less likely to die; where the father had, about 17 per cent. Bangladesh, one of the poorest countries in the world, met its Millennium Development Goals, and the reason usually given is the education of women.
He links it to the peripartum: in poor countries, if a mother dies or becomes critically ill around delivery, the newborn's chance of dying approaches 90 per cent, and half of the under-fives in that family may die too. Mother and child cannot be considered separately.
Hence the phrase he likes: education as a social vaccine. And his conclusion, which is the argument of the whole episode in one line — these are not things that will change because clinicians do clinical work.
He has an explanation for sepsis's invisibility that is worth hearing even if you do not accept it. A disease, he suggests, becomes public the way a religion does: it needs a prophet, a prophecy, a book and a revelation. Cancer got all four around 1969 — Mary Lasker, the promise of a cure, Solzhenitsyn's Cancer Ward, and the moon landing, which made the conquest of anything seem possible. There were some 450 articles on cancer in the New York Times that year, and no American president since has failed to talk about it.
Sepsis has never had that alignment. His other example is warmer: polio was made the biggest disease in America although heart disease killed ten times as many, and the March of Dimes began with mothers collecting coins in baskets. Movements start with ordinary people.
He returns to Osler: medicine is steeped in uncertainty, in diagnosis, in response to treatment, in outcome. His claim is that how we handle that uncertainty determines the quality of our relationship with families.
Families, he argues, respond better to being told the limits of our knowledge than to manufactured confidence: this is what we know, this is where it runs out, I am uncertain — and if it were my own child, this is what I would do. Rodriguez adds the other half, that we force answers that do not quite fit, weight the evidence that agrees with us, and do it because uncertainty is genuinely uncomfortable to sit in.
Put that beside this fortnight's aphorism. Both are about a clinician's willingness to say that the rule they were taught does not quite fit the child in front of them.
Asked what success would look like by 2030, he names targets rather than hopes: half the world's countries with a national sepsis action plan, burden down by about 30 per cent, mortality down by about 30 per cent, and morbidity in survivors improved. He concedes these sound modest. He also says, having been thrown out of more than one health ministry, that eternal optimism is the only way to survive the work.
What happens to your sepsis survivors after they leave?
Not the mortality figure — the follow-up. Is there any? Who sees them, what is looked for, and who tells the school? If the honest answer is that they go back to the GP and nobody looks for anything in particular, say that; it is the commonest answer and it is the one worth publishing.
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