How To Save Antibiotics

Fake malaria drugs are killing 116,000 people a year in sub-Saharan Africa, according to a report released by the World Health Organization (WHO) on Tuesday. And 72,000 to 169,000 children die from pneumonia after taking bunk drugs, WHO noted. Public domain

Recent years have seen Europe grapple with a series of interrelated crises, from continuing economic malaise and widening socioeconomic inequalities, to the mass influx of refugees fleeing conflict, growing xenophobia, terrorism and most recently the potential fracturing of the European Union if a Brexit comes to pass. As such, much of the political debate across the continent has become increasingly insular, with security concerns dominating the policy landscape. But one more global crisis can be added to that growing list—the threat posed by growing antimicrobial resistance (AMR) worldwide to the health and wellbeing of ordinary citizens.

Antimicrobial resistant microorganisms include bacteria, fungi, viruses and parasites that can withstand attack by antimicrobial drugs, such as antibiotics, antimalarials, antifungals and antivirals, so that standard treatments become ineffective and infections persist and spread. AMR transcends national [OD1] boundaries, socioeconomic divisions and affects human, animal and environmental health. From a human health perspective it threatens the foundations of modern medicine: the ability of antibiotics to work effectively. That could impact on their effectiveness in treating anything from common bacterial illnesses, to protecting patients undergoing surgical procedures from subsequent infection, and supporting those with weakened immune systems as they undergo cancer treatments.

Europe has been at the forefront of leading efforts to highlight the risks, build consensus and consult on possible solutions to the problem. In a wide ranging, U.K. government-sponsored review of AMR published last week, the scale of the global problem was laid out, as were potential consequences of inaction and options for collaborative action.

While some of the headline figures touted, such as a warning of 10 million potential deaths annually from AMR or $100 trillion in lost global GDP by 2050 worldwide, are at best speculative from a scientific perspective, and at worst unhelpful in a "boy cried wolf" sort of way, the report has served an important role in bringing the issue to the forefront of political and public discourse.

Many of its analyses and recommendations will serve as useful tools for upcoming discussions at the U.N. General Assembly in September 2016. Importantly, the multisectoral nature of the problem is emphasized in the report with a recognition that over two thirds of antibiotics are used in the animal sector and any successful overarching control strategy will have to take account of the trade and commercial implications of any measures taken.

It also makes a very useful analysis of international agreements and instruments that can help support global measures to tackle AMR, such as the WHO Global Action Plan on AMR brought into effect in 2015 and the revised International Health Regulations, which support countries in dealing with emerging infections (including AMR) and outbreaks that have international implications.

Over the last two decades Europe has done much to increase public and healthcare worker awareness of the issue; improve infection prevention and control procedures; develop sophisticated surveillance systems of resistance patterns and antibiotic usage in human and animal health; and promote rational prescribing.

However, beyond voluntary measures around limiting the use of antibiotics as growth promoters (AGPs)—where they are used at subtherapeutic doses to improve yields in intensified livestock systems—progress has been slower in developing legislation to curtail use of specific antibiotics in the animal and food sector.

For instance, use of fluoroquinolone—a type of antibiotic critical for treating certain types of bacterial infections in humans—was banned in the U.S. poultry industry in 2005, yet has continued to be legal in the European Union. Consequently, resistance rates of human campylobacter infections (a gut-related infection previously effectively treatable with fluoroquinolones) in the US stand at 22 percent, much lower than the European average of 60 percent, as highlighted in a recently released report by the Alliance to Save our Antibiotics.

As Europe has made much better progress than the Americans in voluntarily limiting use of antibiotic as AGPs in livestock production—with impressive reductions of use in the beef and pork industries—an opportunity exists for both sides to further encourage rational use of antibiotics in food and trade through ongoing TTIP (Transatlantic Trade and Investment Partnership) negotiations.

Since TTIP specifically covers the food and pharmaceuticals trades, in addition to other sectors, there is a clear health-related incentive for Europe to encourage the United States to limit antibiotic use by limiting imports of meat produced using AGPs. For its part, the US could help EU politicians see the commercial sense of a ban on fluoroquinolone use in poultry, by making fluoroquinolone-free production a pre-condition to accessing the American poultry market.

Finally, in an increasingly interconnected world where trade, travel and communication networks have grown exponentially, Europe, with its wealth and technical expertise, should do more to improve conditions in low-income regions of the world. It must also encourage and facilitate technology transfer so that low-income countries can develop interventions and solutions that cater to their unique circumstances.

In the years since the September 11 attacks, emerging infections and AMR have been increasingly framed using a security and economic paradigm—partially to pique the interest of world leaders and by extension, encourage high-income countries to invest more significantly in these under-resourced areas of human health.

Unfortunately, one unintended consequence of this approach is that partners from low income countries can often be left feeling suspicious about the intentions of high income country-led disease and AMR control initiatives, particularly in aspects related to surveillance, data and sample sharing, and the international reporting of outbreaks.

Europe needs to resist the urge to frame the issue in narrow, securitized terms, where it seeks to insulate itself from AMR originating from outside its borders—an approach that would be counterproductive and represent a threat to effective global control. Moving forward, European and global initiatives should therefore emphasize the shared risks of AMR, encourage local priority setting and showcase the benefits of improved control to all stakeholders.

Dr Osman Dar is the One Health Project Director at the Chatham House Centre on Global Health Security​