Bacteria have now evolved to deflect our most powerful antibiotics – and we only have ourselves to blame. Antibiotics are over-used in farming and medicine. If we want long-term solutions we need to look beyond the search for new antibiotics. Today, world leaders turn their attention to this global threat and they must use this opportunity to implement a strong international plan to protect an essential global commons.
Since Alexander Fleming’s discovery of penicillin in 1928, antibiotics and other types of antimicrobials have protected hundreds of millions of people from infectious diseases and are now taken for granted as part of modern life. But there are trillions of beneficial bacteria that are essential for our bodies and Earth’s living resources. Unfortunately, overuse is increasingly depleting this global common resource and replacing it with increasingly hard-to-treat resistant microbes. A recent study estimates 200,000 babies die each year as a result of this over-use.
The problem is that the typical solution is to invest in innovation to find new antibiotics. In a recent commentary in the journal Nature, I argue, with colleagues, that this approach tends to downplay important solutions such as hygiene, sanitation, vaccines, or even cultural changes. In fact, the same study estimating the toll of resistance in newborns, also estimated that a pneumococcal vaccine could prevent 11.4 million days of antibiotics treatment for pneumonia, likely reducing the burden of resistance significantly. It is time to reframe the debate and recognize that the true exhaustible natural resource - on par with the ozone layer and our stable climate - is the global community of micro-organisms, not the antibiotics.
Much like fossil fuels, antimicrobials have become crucial building blocks of modern civilization and we do not have a perfect substitute ready. With global transport and increasing rates of international spread, antimicrobial resistance is increasingly becoming a global problem in need of coordinated systemic action. The repeated calls for an organization similar to the Intergovernmental Panel on Climate Change (IPCC) for antimicrobial resistance over the past years are therefore very pertinent.
Today, in conjunction with the United Nations general assembly in New York City, heads-of-state meet to take action at the UN high-level meeting on antimicrobial resistance. Short of a UN convention for antimicrobial resistance, leaders at the UN meeting should set global targets to curb overuse of antimicrobial drugs, limit levels of resistance, and accelerate implementation of the WHO’s global action plan from 2014. Such targets must secure stronger accountability, but must also emphasize the many benefits of microbes.
Micro-organisms are a global public good. They made Earth liveable before humans evolved and they continue to do so. They do this not only by being the engines that run the critical nutrient cycles, secure air, water, and soil qualities, but also by helping our bodies’ digestive and immune systems develop. Without microbes, no humans.
However, human perception of microorganisms does not reflect this, nor does our basic knowledge about them. A 2015 World Health Organization (WHO) survey across 12 countries found that 64% of the public wrongly believe that antibiotics also work for viral infections such as influenza and colds. Such basic knowledge gaps lead patients and physicians to reach for antibiotics without appreciating the costs of antimicrobial resistance.
If leaders at the upcoming UN meeting want to curb the long-term challenge of resistance they must take a diverse and affirmative set of actions. Underlying them all, they must connect the awareness of human civilization to the global microbiome. This involves putting microorganisms on the global school curriculum alongside climate change and the other global environmental challenges.
However, passive learning has rarely been a successful strategy for creating societal change. Luckily, the decreasing costs of gene sequencing technology now allows society at large to participate in monitoring the microorganisms (benign and resistant ones) in their own bodies and in the environment. The rapid increase in citizen and public science as a tool for both monitoring the environment and changing societal norms must now spread faster than antimicrobial resistance.
Non-essential antimicrobial use must be scaled back both in livestock production and in humans.
Without action, global antimicrobial consumption in agriculture may increase 50% and double in emerging economies such as India, China and South Africa. As illustrated by the recent international spread of resistance to the last resort drug Colistin on a mobile gene that can easily be transferred between different bacteria, such a scenario would have far reaching consequences for human health.
One of the most important issues is to phase out globally the use of antibiotics as growth promoters in farming and ensure that farmers or vets do not unscrupulously re-label this as a preventive treatment. A global economic plan to subsidize the transition to antimicrobial free production forms is necessary.
For humans, unrestricted over-the-counter sales as well as black market sales are of the highest priority to curb. In low- and middle-income countries financing of improved sanitation, hygiene and vaccine access is of utmost importance to reduce the reliance on antimicrobials as replacement for these necessary development steps.
The pharmaceutical industry can support reductions in improper use by reallocating some of what they are currently spending on promoting their products, to promote a change in societies’ and doctors’ norms about antibiotic use. In lieu of a recent estimate, we have to rely on a 1998 estimate of marketing spend in the US of over $1 billion. Even a small part of this could make a real difference if used to influence behaviour.
To find an example of industry responsibility for securing resistance-proof use of their products, we can look to the US and insect resistance to transgenic Bt-crops that carry insect toxins to try to reduce pesticide use. But just as for transgenic crops, government regulation will likely be necessary to put such funding mechanisms in place for antimicrobial use.
A first step is to start holding companies accountable for society’s, as well as doctors’, knowledge and norms about antibiotic use. The industry needs an international code on the promotion of antibiotics, akin to that adopted by the WHO in 1981 on the marketing of breast-milk substitutes.
Action on the global goals
The complexity and gravity of antimicrobial resistance calls for an immediate mass mobilization of society akin to what led to action on the hole in the ozone layer. Needless to say, the stakes are high. Drugs that were once lifesavers run an increasing risk of becoming worthless.
In fact, action to maintain the susceptibility of microbes to drugs for global health is a matter of sustainable development and is likely to drive progress across several sustainable development goals. Beyond health, these issues include food security, conservation of natural resources and the environment, and strategies for achieving economic growth and equality.