Why We Must All Fight Antimicrobial Resistance

The international community is finally coming to terms with the urgent threat of antimicrobial resistance. Can the UN high-level meeting be a first step toward tackling it?

By Laura H. Kahn

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Antibiotics are the foundation of modern medicine. Without safe and effective antibiotics, many treatments that we take for granted, such as elective surgeries and chemotherapy, would become too dangerous to perform due to the increased risk of infection. Unfortunately, today, the rise of bacteria resistant to antibiotics is jeopardizing the practice of modern medicine—some bacteria have even become resistant to antibiotics of last resort. The infections they cause are now untreatable: Many fear that we are returning to a pre-antibiotic era in which people died from simple infections.

For years, the medical community has tried to skirt blame for this issue and place it, instead, on the agriculture and veterinary communities, citing the overuse of antibiotics in food animal production. Agriculture, and the food security it provides, is, after all, the foundation of human civilization. And, since the 1960s, antibiotics have been used extensively in modern agriculture—as growth-promoting agents in food animals. Before World War II, the United States relied on fishmeal from Japan and cod liver oil from Norway as important sources of protein for livestock. After those supplies dried up during the war, meat prices skyrocketed, and the federal government was desperate to find a protein substitute. Researchers studying vitamins as one such potential substitute inadvertently discovered that low doses of antibiotics were more effective for weight gain and reduced mortality in chicks. As a result, low dose growth-promoting antibiotics in animal feed were quickly adopted worldwide. Veterinarians have, however, in turn, denied the deleterious effects of these practices; they assert that proper meat handling and cooking would largely eliminate the risks of bacterial food-borne illnesses. Instead, they have pointed fingers back at the medical community for over-prescribing antibiotics.

They have a point. About one in three antibiotic prescriptions in doctors’ offices and emergency rooms in the United States are considered unnecessary. In many ways, antibiotics have been victims of their own success. They’ve been touted as wonder drugs for so long that people insist on using them whether they’re indicated or not. Antibiotic prescription data in the United States and Europe shows that there are vast differences in antibiotic use between countries and across states. Scandinavian countries, for example, work hard to judiciously minimize their use of antibiotics. Mediterranean countries, in contrast, use much larger amounts. Within the United States, Louisiana, Mississippi, Tennessee, Kentucky, and West Virginia use very high amounts; whereas California, Oregon, Washington, Maine, Vermont, and New Hampshire use much less. It is still not well understood why such differences persist—although poverty might play a role—and studies aimed at doing so could shed important new light on this problem.

So who’s right? Is it the medical community, with its tendency to overprescribe, that is at fault, or are the agricultural and veterinary communities really to blame? In a way, both are. But neither is the only culprit.

In my book, One Health and the Politics of Antimicrobial Resistance, I examine the controversy surrounding antimicrobial resistance using “One Health” as a framework. One Health is the simple concept that human, animal, and environmental health are linked, and because of that, complex subjects such as antimicrobial resistance must be examined using an interdisciplinary, holistic approach.

For one, the conversation around antimicrobial resistance rarely includes the environment. It should. According to UNICEF, over a billion people, including around six hundred million in India, further threaten the propagation of resistant bacteria by openly defecating outdoors. This is not solely a matter of poverty; usage of latrines varies across developing countries. Open defecation results in Indians enduring a very high microbial burden in their environment, leading to high rates of diarrhea, malnutrition, and other diseases. And Indian children suffer from very high rates of stunting. It shouldn’t come as a surprise that some of the most antibiotic-resistant bacteria in the world come from India and are now spreading around the globe. In India, antibiotics are a poor substitute for sanitation and hygiene. Even worse, India, and many other low-income countries, allow antibiotics to be sold over-the-counter, further exacerbating the problem of resistance.

As already mentioned, billions of food animals are raised to feed people around the world, with the waste from large-scale pig farms (the animal that receives the most antibiotics) also causing serious environmental contamination. China, in particular, uses enormous amounts of antibiotics in its pig farms. Manure samples from large farms in China with over 10,000 pigs were found to have antibiotic resistant gene concentrations up to 28,000 times higher than samples from farms that don’t use antibiotics. Like human waste, animal manure is typically spread on agricultural fields. It mixes with microbes in the soil and exchanges antibiotic resistant genes.

Another major, though less discussed, source of waste and resistance is aquaculture. In short: We are overfishing our oceans. Aquaculture is intended to ensure a stable supply of fish protein, but we fail to keep in mind that fish didn’t evolve to live in tightly packed pens. The high levels of waste that they generate make them prone to illness. Antibiotics are, therefore, used extensively to prevent and treat disease. Excess amounts of nitrogen and fecal bacteria from these wastes can create dead zones in coastal regions adversely affecting human and animal health.

The bottom line: We are changing the microbial environment in ways that we do not really understand. Indiscriminate antibiotic use is resulting in massive amounts of human and animal waste containing resistant microbes. These wastes contaminate soils, rivers, lakes, and coastal waters. Resistant microbes make their way into wildlife, particularly birds, that help further spread them. All of these factors present significant threats to our ability to treat bacterial infections.

It’s time we finally figure out how to sustainably feed ourselves and maintain our societies without destroying the natural world. Science education must be promoted globally. Students must be taught the germ theory of disease—discovered over a century ago. They need to understand why they should use latrines and wash their hands after using them. They need to understand proper food handling—especially of raw meats. The best treatment is prevention—a strategy that has been sorely lacking, so far, in this debate.

The World Health Assembly (WHA) met in May 2015 to endorse an action plan on antimicrobial resistance. But the issue is so vast and complicated and affects human, as well as animal, and environmental health. For this reason, the WHA has tried to boost its political profile, reflecting the greater urgency on this issue being felt across the international community. (In 2015, the Obama Administration released a National Action Plan to Combat Antibiotic-Resistant Bacteria.) Today, the UN General Assembly will convene a one-day high-level meeting to deliberate on the issue.

Besides improving global sanitation and hygiene, however, what else can really be done? The problem of antimicrobial resistance has been compounded by the dearth of new antibiotics over the past 20 years. Efforts are underway to entice pharmaceutical companies to return to antibiotic research and development. There have been a few new antibiotics approved, but we have a long way to go. Policymakers must make sure to address the regulatory hurdles and financial disincentives that are impeding the discovery of these new drugs.

We shouldn’t put all of our eggs in one basket, however. We should have multiple options in our therapeutic armamentarium. Vaccines would be an important prevention strategy in the fight against bacterial infection. Unfortunately, as with antibiotics, few pharmaceutical companies remain in the vaccine business. Public animosity toward vaccines doesn’t help. Another option is to explore the use of bacteriophages—tiny viruses that are the natural foes of bacteria. They are the most prevalent bioform on the planet that infect bacteria and kill them. We should harness them and make them work for us. Unfortunately, the technology for bacteriophages is over a century old. The scientific community has been dragging its feet in developing them because they are viewed as “Soviet” science. Government support for bacteriophage (viruses that are used to infect bacteria) research should also be increased. There are a few existing NIH grants at the moment, and hopefully, more funding will become available soon. On the agriculture side, the fiscal year 2017 U.S. Department of Agriculture budget has allocated zero dollars for animal health and disease research, making advances in this area impossible. This is true despite the fact that bacteriophages have been approved for use in food safety, and have the potential to act as a substitute for antibiotics in food animal production should better funding be available to study them.

Ultimately, we have only one planet. Instead of treating it like the life-sustaining gem that it is, we are dumping our wastes on its land, water, and air. Antimicrobial resistance is only one sign and symptom of our deteriorating biosphere. And this is exactly why we need to use an interdisciplinary One Health approach to address this problem. The question is: Can we generate the political will to actually do something about it? We can only hope that this week’s meeting might elevate the discussion enough to hopefully move us a step or two closer.

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Laura H. Kahn is a physician and research scholar with the Program on Science and Global Security, Woodrow Wilson School of Public and International Affairs, Princeton University. She is a regular columnist for the Bulletin of the Atomic Scientists and has authored two books, Who’s in Charge? Leadership during Epidemics, Bioterror Attacks, and Other Public Health Crises, and most recently, One Health and the Politics of Antimicrobial Resistance. She is a Fellow of the American College of Physicians and a recipient of the New Jersey Chapter’s Laureate Award. The American Veterinary Epidemiology Society recently awarded her with the K.F. Meyer/James H. Steele Gold-Headed Cane Award for 2016.

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