ANTIBIOCALYPSE: HOW DO WE RESPOND TO SUPERBUGS?

by Gerry Bloom, STEPS Centre Health domain convenor

On August 11 the Lancet published an article that demonstrated the emergence of a new antibiotic resistance mechanism (known as NDM-1) in India, Pakistan and the UK. The article points out that many of the UK people carrying resistant bacteria had visited the Indian sub-continent during the past year or had links with these countries. The authors warn that the spread of bacteria resistant to almost all known antibiotic drugs could pose a serious public health hazard. What’s to be done?

Today, the British newspapers have responded to the issue from a number of points of view. The Daily Mail argues that “we’ve only ourselves to blame”, highlighting that people seeking inexpensive plastic surgery in India are amongst the carriers of the new bug to the UK. The Guardian contemplates “a world without antibiotics”, calling for world-wide surveillance to identify emergent resistant organisms. An editorial in the Financial Times (registered users only) emphasises the need for investment in new anti-microbial products.

This is the latest of a stream of stories about the emergence of organisms (strains of HIV, tuberculosis and malaria) resistant to existing treatments. These emergences share a common pattern: a new drug is developed, and its use spreads rapidly, including in partial doses. The problem is that in places where many people have a lowered capacity to fight infection because they are malnourished, are exposed to multiple infections through contaminated water, or have a chronic infection such as with HIV, the possibilities that a new strain of a bacterium or virus will take hold and spread are increased.

This isn’t fully surprising. The Lancet article refers to a past editorial by AD Ghafur in an Indian medical journal about the availability of antibiotics in that country’s informal markets and a prediction of the emergence of resistant organisms. We need to recognise the consequences for global public health of the persistence of severe poverty and the rapid spread of health-related markets. In many parts of the world, poor people obtain most of their drugs from informal health workers or shops functioning largely outside a regulatory framework. A substantial proportion of these products are counterfeit and of low quality. People often buy several antibiotics and they do not necessarily take a full course of treatment. In this context, the rapid emergence of resistant organisms is inevitable.

What can be done?

One option is to try to protect the UK population through more effective surveillance and measures to reduce exposure of people to emergent organisms. The Lancet article, for example, opposes proposals that the British NHS refer patients to Indian hospitals as a way to save money.

A second option would be to prevent the easy movement of pharmaceuticals to localities without a well-organised health system. This would, in effect, deny many of the world’s poorest people access to effective drugs.

Neither option is politically acceptable or practically feasible in a world of increasing movement of people between countries and rapid communications, where it is almost impossible to avoid links between the very rich and poor people seeking health care in markets thousands of kilometres away.

We need to recognise the potential gravity of the problem of treatment resistant organisms. Recent efforts to make drugs widely available at an affordable cost have made a major impact on the lives of millions of people. They now need to be complemented by a similar effort to ensure that drugs are used responsibly. This cannot be achieved by simply announcing new regulations, which are unlikely to have much impact on the largely unorganised markets through which a large volume of pharmaceuticals flow.

An effective response to this problem needs to combine research on new pharmaceuticals, the creation of new global capacities for surveillance and measures to enable poor people to gain access to effective drugs while reducing the risks of resistant organisms. These measures will require a new kind of partnership between governments, pharmaceutical companies, providers of health services, participants in informal health markets and poor people, themselves, to improve access to anti-viral and anti-microbial drugs and ensure their responsible use.