Antibiotic Resistance: End of a winning streak

Antibiotic resistance is rising again bringing memories of old times when death from small infections was common. To solve it requires dealing with the subject of the individual versus the society.

Amidst the myriad wars being fought by the world from Ukraine to Iraq, it has ignored a new terror threat emerging on the world scene. Arguably, it is much more dangerous than any other we have seen for decades for increasing antibiotic resistance in microbes has the potential to kill far many people than any modern war does.

The consequences of rising antibiotic resistance can nullify many advances of modern medicine. We must be ready to face and win this war. However, winning this war would require a massive and collusive social effort. And in the process we will need to find difficult solutions on the issue of individual and social responsibility, the essence of a free society.

There has been an upsurge in reports of multi-drug resistant strains of bacteria in different parts of the world, mostly in India. The news of the infamously nicknamed “New Delhi Superbug”, a multi-drug resistance carrying bacterial strain had caused much controversy and scare. It is probably obvious for some to respond hysterically to the naming of the bacterium as an evidence of some deep rooted conspiracy.

But germs can spread, sometimes faster than news. A bleak future stares in our face if we continue to be indifferent towards the threat posed by germs rapidly acquiring resistance to drugs. The whole of our antibiotic quiver is fast becoming blunt. We are running out of time in preparing for the emergence of more “deadly” bacteria that can cause widespread disease at worst, and cause preventable deaths at best. This scenario was not unanticipated.

Dr. Alexander Fleming, the discoverer of the first antibiotic, himself had warned against letting the bacteria win the evolutionary war against our drugs by sheer public health mismanagement. And considering that India still accounts for a significant share of infectious diseases in the world, it should be one of the bigger problems on society and policy makers’ minds.

Antibiotic resistance has now assumed dangerous proportion, and there are realistic threats that the recently reported “superbug” is only a tip of the iceberg. For the last 50 years, antibiotics and vaccination have saved millions of lives but we are soon reaching a stage where the enemy has learnt to hedge against our arsenal. But what is the cause of the advent of these resistant microbes?

How do germs become resistant?

Bacteria, like all living organisms, evolve and change against any hurdle we place against their growth. In scientific language, when a selective pressure is posed to a living being, over many generations it will keep selecting those individuals who are better off than the others in fighting against the pressure. Much like what happens in real life. Since bacteria divide so quickly, even a single one amongst the millions that could somehow resist the antibiotic would win out. This winner will divide and produce a whole population that is resistant to the drug. Each time a person uses an antibiotic, he raises the chance of creating a resistant strain. Therefore it is important that drug compliance is strict, and it is used sparingly only for infections that cannot be controlled otherwise. That, we very well know, is hardly the case.

Emergence of multi drug resistant bacteria will inevitably cause severe public health issues in future. Half a century ago, it was common for a small cut to cause septic shock and death. Antibiotics significantly reduced these fatalities in the population. That fortunate phase is already showing signs of decline. My father not long ago succumbed to septicaemia due to a minor lung infection that turned out to be resistant to many antibiotics. Small infections that can be easily controlled today if they turn dangerous become fatal if the drug is not going to work. Most surgeries, including minor ones like for cataract and vasectomy, depend on our ability to control infection to negligible extent. This may not turn out always to be the case in future.

Not merely medical but a societal problem

But why are resistant microbes emerging so frequently, with sometimes two, three, or more drug resistance in a single microbe? There are many reasons. Antibiotic is one of the cheapest ways to solve an infectious disease problem. This is particularly true in the light of extremely low patient compliance in the developing world, which itself stems partly from the low hospital penetration. Alternative to the cheap pill is continued monitoring, quarantine, and possibly prolonged hospital stay. All of them are expensive alternatives that are realistically not possible to provide.

But another pernicious cause, exclusive to a few countries including India, is the over-the-counter availability of antibiotics, requiring no real prescription from a medical doctor. It is not uncommon to find well educated individuals taking antibiotics as a first option pill at the onset of slight fever or throat infection without the bother of a doctor. Antibiotic usage is so rampant in many parts of the world, that it is extremely common to find multi drug resistance non pathogenic strains in patients. The brahmastra of medicine is callously used for tiny skirmishes, without any understanding in the society that each time an antibiotic is used, we risk making it redundant in future. There are other reasons, the chief one being its rampant use in poultry and dairy industry.

But the central reason one is a socio-economic conundrum faced by society on various occasions where incentives and disincentives to an action cannot be fairly priced. Where contractual laws are well executed, an action that benefits a person but harms another one can be resolved with ease. For example, if I keep my vehicle in front of my neighbor’s door blocking his way, the problem could be solved by either the victim suing the beneficiary, or mutually settling at a price for the discomfort.

In contrast, when an action by an individual or group causes localized advantage to the actor, but diffused harm to the society at large it becomes difficult to provide disincentives to limit the action. When a person emits smoke from his vehicle, it is difficult for the ones who are suffering in return to be compensated in any way.

Antibiotic usage is quite analogous to this situation. When a person wants to use antibiotic for a simple fever, she certainly benefits herself immediately, but contributes towards potentially creating resistance in bacteria that may harm someone else in the society. Therefore to limit antibiotic usage is a very difficult problem that has to be addressed with a comprehensive effort involving public education, regulation, policing, and control over drug manufacturing and distribution.

In a country like India, where the government is large where it should not be, and exists sparingly where it should, this conundrum gets exemplified on many occasions. Emergence of antibiotic resistance is one example. But why are we not producing new drugs to deal with these changed bugs?

A big reason is that until now infections have been a poor world problem, and the rich world that largely funds most research has little incentive to invest in finding solutions to problems that is not theirs to worry about. Antibiotic development for other reasons is also not a very lucrative business for most pharmaceutical firms. The developing world must take a lead in creating incentives to usher new innovations in developing new methods to control bacterial growth (antibiotics, and other alternative methods). This would necessitate extended patent protection for new drugs, and liberation of controls to bring the drugs from laboratory to market.

Rewinning the battle

A comprehensive strategy to limit emergence of resistance needs to be considered. Unfortunately, due to the above socio-economic dilemma, it is one of the rare problems of society where the government needs to come in. Antibiotic dispensing system in India must be completely overhauled, and antibiotics should be available only on prescription, like in most other countries.

This is easier said than done. Such cheap pills which are mostly generic and not patent protected will inevitably fall into black market if a regulation limits their availability. Another solution may be to train doctors and medical students of the danger of callous and rampant antibiotic usage. Though its effect will only be limited, it is relatively easier to implement a policy, considering the uniformity of medical education curriculum.

A huge public education exercise and building of general awareness towards the danger of unnecessary antibiotic usage is needed to educate the public about the danger. These methods are costly, but the cost can be shared amongst various elements in the society. Antibiotic usage in poultry, and dairy usage should be strictly limited. It is one of the biggest causes of emergence of resistant bacteria. As will all regulations of supply, these will inevitably result in black marketeering of antibiotics, but at least the patent protected non-generic drugs can be salvaged from becoming redundant. The developing world must invest in and incentivize research and development in new anti-bacterial drugs, and methods to test bacterial sensitivity.

All these solutions, even in totality, will not be perfect. But the danger is too big, and not far away in time, to allow us the luxury to wait for the best single solution to emerge. If the use of antibiotics is not controlled, humanity is destined to take a huge step back, and return to times when death due to infection was not an uncommon event.