Photo courtesy of Martin Cathrae.
A few weeks ago, Great Britain’s top medical officer, Dame Sally Davies told the U.K. press that the proliferation of antibiotic resistant diseases could bring about “apocalyptic scenario” for the European power that poses as much of a national security threat as terrorism. On the other side of the pond, America has seen its fair share of antibiotic resistant viruses sweeping through hospitals, but the issue has seen little, if any, coverage in the mainstream media.
To make heads and tails of these warning signs, we turned to Dr. Rachel Nugent, associate professor and director of the Disease Control Priorities Network at the University of Washington’s Department of Global Health.
Dr. Nugent is also the former deputy director of global health at the Center for Global Development. During her term from March 2007 to March 2011, her research focused on funding for non-communicable diseases in developing countries and the effects of demographic changes on development. She led CGD’s Demographics and Development in the 21st Century Initiative, chaired the Drug Resistance Working Group and Initiative, and was co-chair of the Working Group on UNFPA’s Leadership Transition.
BreakThru Radio: The U.K.’s chief medical officer, Dame Sally Davies recently stated that antibiotic resistant diseases pose an apocalyptic threat to the country as much as any national security threat. Is this in any way hyperbole?
Rachel Nugent: Yes and no. Actually, “apocalyptic” is a pretty strong term and I think that most people would understand it to mean widespread devastation or doom like in the movies. That’s not going to happen because of antibiotic resistance, and it seems to me a bit like crying wolf to say that it is. But on the other hand, apocalyptic does mean the end of life as we’ve known it and this is true. For instance, how many times in your life have you just turned to the doctor for an antibiotic without even thinking about it if you couldn’t get it? It used to be way back in the last century died from all those things kids get when they’re young [like] pneumonia, and in poor countries they still do because of the lack of the right drugs, because of the lack of antibiotics.
So I guess I would say not if but when we lose the value of many of these cheap, effective drugs like Penicillin or some drugs called Fluoroquinolones, which is an antibiotic class commonly used to treat respiratory infections like pneumonia or drugs for urinary tract infections. We are losing those drugs and it will be a fully changed world when we have lost them.
So just to get back to your question, as far as I know the origin of Dame Sally’s comment was the Global Risk Report released last month by the World Economic Forum and it showed drug resistance to be a major threat to the world, both for its potential impact and likely probability – well, actually it’s not really potential because we are feeling the impact and it is happening.
But these risk assessments come from a very subjective process of surveying business executives, and other world leaders have been involved as a respondent. And it’s really good to see that drug resistance is getting that kind of attention from movers and shakers not like me, but real movers and shakers. Many things on that list are what I would call slow motion crises like drug resistance. And we should respond to them systematically, comprehensively and rationally with costs and benefit in mind, not as though the sky is falling. So that’s my response to her.
Dame Sally Davies. Photo courtesy of NHS Confederation.
BTR: It seems like one of those issues that if we don’t pay attention to it, sooner or later it falls off our radar and things can really get out of control. Is it worth it to at least be hyperbolic about the issue at this point so it gets on our radar, considering all of the other pressing issues surrounding the world: food shortages, terrorism, everything under the sun basically. Is it worth it to at least be hyperbolic in this way so that we can start talking about the issue?
RN: Yeah, if that’s what it takes then I guess it is worth it. I’d like to say we shouldn’t have to have that kind of hyperbole and it would worry me in a way it does worry me because um, this is an invisible thing. You know, people can’t see it to say this is apocalyptic. They’re kind of like, “Where? Where is the apocalypse?” and I just think we need to be able to speak rationally about it and have a good discussion about what it takes. It takes resources, making people aware of the effect it can have on their everyday lives. It takes that kind of a discussion, which I don’t think her statements really lead us towards. So I would accept your premise if that was the only way to get there but I suspect it’s not gonna get us there.
BTR: Is this merely an issue of economics specifically that in twenty years or so time that our demand for antibiotics will outstrip the supply given the proliferation of these kinds of diseases? In which case is the solution that we must take antibiotics more viable? Somehow develop new and better ones in the future?
RN: Really good question, two questions really. Is it merely economics? No, it’s not just economics. I mean our entire of medicine whether we’re talking about high-tech Western medicine or simple child health interventions in poor countries relies on cheap antibiotics. If you need surgery for anything, whether a person is delivering a baby or having a tooth pulled, you need antibiotics. And the progress that we’ve seen in reducing global child deaths from around twelve million a year to less than eight million a year, which doesn’t sound like progress really ‘cause it’s so high, is huge progress in less than a decade is due in large part to increased access to antibiotics and antimalarials for common childhood diseases as well as vaccines. So that’s about medicine.
Now, when it comes to the economic part we cannot treat the threat out of these diseases permanently. But these diseases don’t have to proliferate. They are, in fact, getting less common thanks to greater vaccine coverage and other things, and that’s one way to increase the lifetime of the antibiotics that we do have. So there is economics in this too.
You ask about solutions. We do need to increase development of new drugs. That’s not happening for a variety of reasons, a lot of which are economic reasons. For instance, it’s not profitable enough for companies to invest in R and D for antibiotics. It’s also pretty hard science these days, it’s harder science than it used to be because we’ve made the easy discoveries in antibiotic science and there are new pharma business models.
Those are all reasons why we’re not seeing adequate R and D in antibiotic classes. And just to expand on one of those reasons, we haven’t protected the value of the drugs we have but they are still cheap to buy. Antibiotics cost very, very little — most of them. That often means that they’re overused and there’s no incentive for companies to come up with new ones, unlike their incentive to develop drugs for chronic diseases, for instance that people would be taking year after year or very expensive cancer drugs that insurance companies will pay gobs of money for.
So there is definitely economics in this, now just to go to your last point about solutions. There are a number of solutions, and in our report at the Center for Global Development that we published a couple of years ago, we pointed to a number of solutions in addition to increased vaccine coverage for prevention. We make antibiotics more available in some cases but we actually make them less available in a lot of cases as well.
What we mean by that is the problem is often defined by underuse. That can mean under use when people don’t take the full dose prescribed to them by their doctor, and therefore, don’t kill the pathogens completely with the drugs. Or when people can’t afford to buy many pills like in poor countries, they’ll often buy a couple of bills because that’s all they can afford. They take enough to start feeling better but again, not enough to fully kill off the disease. And that makes a perfect environment for resistance to develop.
But, more often the problem is that people are getting the wrong drug for the disease that they have, or a poor quality drug without enough of a curative ingredient in it, but just enough to create resistance pressure and this is what we would call over use or misuse or inappropriate use. So there’s a lot of complications to how to take these drugs right.