Antimicrobial Resistance: Facing the Rise of a Global Threat

Superbugs: An Arms Race Against Bacteria By William Hall, Anthony McDonnell, and Jim O’Neill

Cambridge, MA: Harvard University Press; 2018 246 pages; ISBN-13: 978-0674975989

Even if most people know little about medicine and public health, we have all heard about and have probably taken antibiotics. As one of the greatest medical discoveries, effective “antibiotics provide a backbone to the entire health care system.”^(p69) They are key to the treatment of common infectious diseases, and their availability has been vital to the development of medical procedures, such as chemotherapy, organ transplantation, diabetes management, and surgeries (e.g., cesarean deliveries and hip replacements).

Antibiotics, “the world’s first blockbuster drugs,”^(p29) met a high demand and revolutionized both medicine and the pharmaceutical industry, saving lives and ensuring profits in the decades after World War II.

However, bacteria have kept up with, and often outpaced, scientific progress. We are now witnessing the rise of the so-called superbugs: microorganisms that have developed antimicrobial resistance (AMR), a defense mechanism against the very drugs used to eradicate them.

Superbugs: An Arms Race Against Bacteria by William Hall, Anthony McDonnell, and Jim O’Neill focuses on resistance to antibiotics that has developed in bacteria. It expands on the work of the Review on Antimicrobial Resistance, which was commissioned to estimate the global scope and economic and policy aspects of AMR, and proposes realistic solutions.¹ With insightful and action-oriented analysis, the book depicts a worrisome picture of the worldwide problem of drug resistance. It is eye-opening about the complexity and scale of this threat to human and animal health. The authors analyze the problem through economic and policy lenses and convincingly present feasible solutions, which makes the book an essential educational resource for medical and public health professionals. Interwoven into the rich content of Superbugs are views of international experts in the field, including doctors, academics, politicians, and leaders who have observed drug resistance firsthand.

The book’s first three chapters discuss the nature and history of AMR, and the following four elaborate on the proposed solutions, with a concluding chapter on next steps and international awareness and action.

A GLOBAL THREAT

Ever since antibiotics were discovered, there have been warnings that their unnecessary or inappropriate use would accelerate the rise of resistance and lead to these precious medicines becoming ineffective.² Hall et al. estimate that about 1.5 million of the world’s population dies each year because of drug-resistant infections. AMR increases the cost of health care, and it complicates the fight against multidrug-resistant tuberculosis, malaria, and gonorrhea. In addition, bacterial strains with resistance to the last-line, carbapenem antibiotics have “emerged, diversified, and spread to become what’s now seen as the pinnacle of our resistance problems” (Neil Woodford, head of the AMR unit at Public Health England).^(p195)

AMR is “a problem of a global commons, which means that what happens in one country affects other countries as well” (Ramanan Laxminarayan, director of the Center for Disease Dynamics, Economics and Policy).^(p116) Addressing this threat requires intergovernmental and multisectoral efforts. In recent years, the issue has been discussed at the highest levels as part of the international political agenda, with commitments to action from government officials.³ Former UK prime minister David Cameron called the fight against drug-resistant infections the “perfect example of something that [needs] international action.”^(p197) However, tackling rising drug resistance will undoubtedly be challenging when, according to Tedros Ghebreyesus, World Health Organization director general, many health care systems in the world remain underfunded and weak. That is why this serious problem is also a remarkable opportunity for the G7 and the G20 to act, together with international and charitable organizations, the pharmaceutical industry,⁴ and the private sector.

INTERVENTIONS AND INVESTMENT IN SOLUTIONS

Superbugs elaborates on a variety of interventions to counter drug resistance: improving infection prevention and control, developing new antibiotics and rapid diagnostics, stopping unnecessary use in humans and in agriculture, and cleaning up supply chains. A number of notable initiatives have been and should be undertaken to ensure the effectiveness of these interventions. These include raising awareness of AMR through campaigns, underscoring the importance of prevention, studying dosing practices and patterns to improve prescription accuracy, strengthening health and surveillance systems in countries, and involving governments, food production, and retail companies in reducing the levels of antibiotic use. As José Graziano da Silva, director general of the Food and Agriculture Organization of the United Nations, has pointed out:

Antimicrobial resistance is a problem not just in our hospitals, but on our farms and in our food, too. Agriculture must shoulder its share of responsibility, both by using antimicrobials more responsibly and by cutting down on the need to use them, through good farm hygiene.^(p176)

To emphasize the importance of investing in these solutions, the authors reveal the unsettling price that would have to be paid if the problem of AMR is neglected:

The cost for all the interventions the Review on Antimicrobial Resistance recommended for tackling drug-resistant infections came to $40 billion over a decade, or about $4 billion a year. The cost of inaction, a prospective cumulative impact of $100 trillion by 2050, puts this investment into perspective.^(p204)

Money to fund these interventions could be raised from various sources, including governments, multilateral and philanthropic organizations, the pharmaceutical industry, and taxes. An intervention of $3 to $4 billion per year would be affordable for most governments and would represent approximately 0.05% of the G20’s annual spending on health care. Because high-income countries already spend 1% of their total health expenditure on tackling drug resistance (the United States spends about $20 billion a year, and the United Kingdom $1.5 billion), these countries could lead the investment to counter AMR globally.

It is essential to invest in research on and development of new antibiotics,⁵ and the book shows how incentive structures can encourage this process. Countries could finance the development of antibiotics out of their existing health budgets (requiring about 0.05% of health expenditure) or collect funds through taxes on generic antibiotics or antibiotics used in agriculture. Charging pharmaceutical companies for the cost of developing new drugs is also justifiable, because antibiotics enable the pharmaceutical industry to make substantial profits in medical procedures:

A 0.16 percent tax on all drugs sold by pharmaceutical companies in the world could be used to fund the development of new antibiotics, while a slightly higher tax of 0.4 percent could fund all of the global interventions that are required to stop drug-resistant infections.^(p111)

ACADEMIA MUST CONTRIBUTE

With their multidisciplinary expertise and work in research and teaching, academic institutions can be major contributors to the effort to combat drug resistance. Emphasizing the topic in the curriculums of medical and public health schools would prepare future practitioners and leaders in the field by providing them with knowledge of the problem and actions to tackle it. Doctors and veterinarians will always play a decisive role in treating infections and improving antibiotics prescriptions.

Hall et al. observe that, presently, academia is not sufficiently involved in addressing this problem, although a lot of the basic research connected with early-stage drug development is conducted at universities. A new public–private partnership has been created to make early-stage research a priority and fund the clinical trials of promising new antibiotics: CARB-X (the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator).

A SUPER BOOK

Superbugs is a super book in many ways—a crucial read on the rise of drug resistance and a range of practicable solutions to it, both from an educational standpoint and as a compelling call to action for various societal actors to contribute to countering this global threat. The book demonstrates how solving the problem of AMR would have “much wider benefits: for public health, for the environment, and for sustainable farming and society in general.”^(p215) Since human activity has led to this problem, we must find ways to resolve it, and the book marks a path for how this can be accomplished.