United Nations of antibiotics: Follow words with action
View(s):By Dr. Sanjaya Senanayake
Many readers would know that the United Nations convened in New York recently for its 71st General Assembly. It was a “Who’s Who” of world politics as a variety of weighty issues were discussed amidst much fanfare. Fewer readers would be aware, however, of a one-day high-level U.N. meeting on September 21 to highlight a matter not typically associated with global diplomacy – antimicrobial (antibiotic) resistance.
This was a remarkable meeting. It was only the third time that the U.N. had convened to discuss infection-related matters, the others being for Ebola and HIV/AIDS. The political and diplomatic recognition of a medical matter on the international stage of the global theatre that is the U.N. is an indictment of the issue’s importance. This was further reinforced by U.N. Secretary-General, Ban Ki-moon opening the session with the sobering facts of the deaths of 200,000 newborns annually from antibiotic-resistant superbugs.
A creepy crawly threat to human health. Reuters
As an Infectious Diseases Physician constantly submerged beneath the rapidly flowing (and growing) river of the last few years that is antibiotic resistance, my brief resurfacing to partake of a breath in the real world brought the surprising realisation that antibiotic resistance is still a matter at the peripheries of the awareness of most people. With so many issues to contend with both internationally and regionally, such as climate change and refugees, it’s understandable that the global community’s radars are saturated with a myriad of concerns beyond those of antibiotic resistance. Ebola captured the public’s imagination with a frenzy and infectiousness akin to the disease itself, as developed nations contemplated contagion with a developing world infection. Perhaps that’s the point: antibiotic resistance’s infiltration has been a gradual one, unlike Ebola’s dramatic entrance in 2014. Yet the long-term potential devastation to the global community attributable to antibiotic resistance is greater than that of Ebola. Currently, it’s estimated that 700,000 people die annually from antibiotic resistance, with that figure rising to ten million by 2050 if the problem is not addressed. Also, in evolutionary terms, both the emergence of antibiotic resistance and its progression have been of a truly frenetic pace. It took 160 million years for dinosaurs to come and go: antibiotic resistance has become a major issue only eighty years after the emergence of antibiotics – that’s within a Darwinian blink of an eye.
Inappropriate use of antibiotics is a major factor driving antibiotic resistance – that goes without saying. This doesn’t only apply to doctors giving antibiotics incorrectly to patients in a clinic or hospital setting, but also to over-the-counter use of antibiotics. Over-the-counter use of antibiotics is when you – the reader – decide without medical advice that you need a course of antibiotics e.g. for a sore throat, and go to the pharmacy and buy it without a prescription or the doctor’s blessing. The issues here are that you may not need an antibiotic as most sore throats are due to viruses and won’t respond to antibiotics, that you choose the wrong antibiotic and that you use the wrong dose and duration of antibiotics. All these factors drive antibiotic resistance and the development of superbugs.
But while inappropriate use of antibiotics is a major contributor to antibiotic resistance, the problem – and therefore its solution- is not that simple. People are astounded to learn that most of the antibiotics in many nations are given to animals, with a relative smattering for humans; however, through our contact with animals (e.g. via consumption of meat), we are exposed to their resistant bacteria. A recent example is the identification in pigs in China of a superbug carrying a highly resistant gene (mcr-1). Even vegetarians are at risk because the water in which the legumes have been irrigated on a farm can be contaminated with animal waste, along with the animal’s resistant bacteria. Nor can island nations be complacent that their geographical isolation engenders a safety net keeping superbugs at bay. For one, superbugs are already here. Secondly, the ease of global travel means that any of us can unwittingly bring back superbugs in our bowels from travel destinations, tantalisingly close to but beyond the means of detection of the intrusive lubricated gloved digits of our border control officials.
A new phenomenon in global travel is “medical tourism”, where people go overseas to undergo a medical or dental procedure, often because the cost in their own country is prohibitive. With regard to picking up superbugs, this is worse than going overseas to a holiday resort, because the medical tourist will be immersed into an overseas healthcare environment where the concentration of superbugs will far outweigh those found in the resort.
More new antibiotics are also needed, but for pharmaceutical companies, the financial incentives in their production are limited. A common problem is doctors not using a fantastic new antibiotic immediately, but rather keeping it in reserve as a last resort against antibiotic-resistant superbugs. While this is sound antibiotic stewardship, it’s not an ideal business model for the pharmaceutical company that’s invested millions in developing and marketing the antibiotic. Imagine Apple releasing the iPhone 7 and being told by consumers that it’s so good that they’ll only use it once their iPhone 6 breaks down! To add insult to penury, by the time the antibiotic is being used widely, its patent may have expired, allowing other companies to produce their own versions. This is by no means an endorsement of “Big Pharma”, but simply an illustration of one challenge that needs to be overcome to curb antibiotic resistance.
Such complexities on such a scale demand a multidisciplinary solution with global political backing. The process has begun. In 2014, the UK government commissioned a Review on Antimicrobial Resistance led by Jim O’Neill – not a doctor, but a distinguished economist who invented the term “BRIC” (Brazil, Russia, India, China). The following year, President Obama released his National Action Plan for Combating Antibiotic Resistant Bacteria. At the World Economic Forum in Davos, around 100 pharmaceutical, and other companies became signatories to an agreement to work closely with governments to reduce antibiotic resistance. The pledge made by all 193 U.N. member nations at September’s extraordinary meeting to combat antibiotic resistance is the pinnacle of such international collaboration; however, the inspiring rhetoric of the present must be followed up with action and funding; otherwise, the relentless march of antibiotic resistance will continue, and the bright light of antibiotics will flicker briefly in history before being extinguished forever.
(The writer is an Associate Professor of Medicine at the Australian National University)