The world is rapidly running out of antimicrobial medicines. The lack of these essential medicines means that even the simplest of infections could soon become fatal, taking us back to the dark ages of medicine. The bacteria, viruses, and fungi that infect us develop resistance to treatment naturally, but sustained, excessive use and abuse of these medicines is rapidly accelerating this process. Now, the consequences are beginning to bite us, and their effects will be felt nowhere more brutally than in the developing world.
The impact of drug resistant infections will be devastating. Currently, 700,000 people are killed by drug-resistant infections every year. By 2050, that number is predicted to rise to 10 million. The consequences will be far reaching; global GDP is predicted to fall by up to 3.8%, creating chaos far beyond the 2008 economic crisis. There will be little hope for recovery, as hospital costs soar from 300 million USD to 1 trillion USD a year, and international trade rapidly declines. The cumulative effect will push 28.3 million people into extreme poverty, and the impact of this will be felt most keenly in the developing world. Of the 28.3 million people pushed into poverty, 26.2 million people will live in low-income countries, where GDP is predicted to fall by up to 5%. Infectious diseases are already a leading cause of death in the developing world, where there is a fundamental lack of healthcare and essential medicines. These countries are also significant drivers of resistance, where the problem is exacerbated by unregulated prescriptions, poor drug quality, counterfeiting, and excessive use in livestock.
We live in a hugely interconnected world, where air travel and mass migration have allowed resistance to flourish around the globe. Now, antimicrobial resistance is a global problem requiring a global response. The World Health Organization (WHO) is leading the international response by developing a global action plan. It outlines several measures, including raising public awareness to reduce drug usage, improving sanitation, promoting vaccinations, and increasing funding for research. The international community desperately needs pharmaceutical companies to start producing new drugs, and a sea change in public attitudes towards their usage. These are neither easy problems nor easy solutions. Otherwise, Margaret Chan, Director-General of the WHO, acknowledges that antimicrobial resistance will “be disastrous for human health” and “penalize the poor more than anyone.”
Causes of the crisis: antimicrobial abuse in the developing world
Resistance develops when pathogens, the microbes that make us ill, mutate their DNA in a way that enables them to either break down antimicrobials, or change their appearance so that they are no longer targeted by them. This process is rapidly on the rise, owing to excessive use and misuse of drugs in both the developed and developing world. However, this process is significantly aggravated in the developing world, where the problem is vastly complex, but mainly driven by poverty.
Availability of antimicrobials is a huge driver of resistance in the developing world. In many countries, these medicines can be bought without prescription, and are often sold for profit, or to accommodate what the patient can afford. Low-income countries with poor medical infrastructure have low doctor-patient ratios, meaning doctors have little time to treat patients and can often mistreat infections. Indeed, a community of physicians in Lebanon was found to be incorrectly prescribing antimicrobials in 52% of cases, owing to a lack of resources. Meanwhile, in some of the developing countries of Africa, people living in poverty often turn to traditional healers for herbal remedies, waiting until the severity of their illness progresses to use antimicrobials.
Issues with drug quality are rife in the developing world. Heat and humidity degrade medicines, while counterfeit or ‘watered down’ drugs at sub-therapeutic doses create an environment where resistance thrives. Researchers from Cameroon found that out of 284 antimalarial treatments sold by ‘street pharmacists,’ up to 32% of medicines were counterfeit and contained insufficient active ingredients, or no drug at all. Such medicines have deadly consequences for the recipients and dangerous implications for resistance.
Response to the crisis
Governments around the world have developed plans to combat resistance. Yet, action is severely lacking in developing countries, particularly African countries without effective regulation. Low-income countries often lack the infrastructure and resources to tackle antimicrobial resistance. Indeed, the countries of Africa form 15% of the world’s population, but carry 25% of the disease burden, meaning that with limited resources, resistance isn’t the priority it needs to be. A few African countries are involved in the Global Antibiotic Resistance Partnership, aiming to develop policy proposals for antibiotic resistance in low-income countries. Action groups have been established in India, Kenya, South Africa, Vietnam, Tanzania, Uganda, and Mozambique, yet Ethiopia is the only African country with an antimicrobial resistance (AMR) action plan.
The lack of advanced resources means that the focus falls to prevention. Overcrowding and poor sanitation plague developing countries, and are key contributors in aiding the spread of resistance. Improving basic hygiene and healthcare are already key priorities for low income governments; they are vital in protecting population health and tackling the spread of resistant microorganisms. Vaccines are invaluable in preventing common infectious diseases such as measles and smallpox, and are estimated to save 3 million lives a year. They indirectly benefit entire populations from outbreaks through herd immunity, in which unvaccinated individuals are less likely to contract infection owing to higher numbers of vaccinated individuals around them. As such, vaccines are seized upon by governments and international charities. However, preventative measures have so far been insufficient in constraining resistance, and far more needs to be done to tackle such a complex problem.
What needs to be done: our global responsibility
Most developing countries are not lacking in legislation, but in resources. Governments need to tackle every step of the pipeline, from production through to distribution and consumption. Despite the challenges imposed by poverty, progress is being made, yet far more needs to be done to address each issue at its core.
The production of antibiotics is a key issue for both the developed and developing world. Pharmaceutical companies have not developed a new class of antibiotics since 1987, perhaps not unjustifiably. It costs a minimum of 300 million USD to bring a drug to market, and many of these drugs often fail clinical trials, at significant cost. Further, resistance greatly shortens the lifespan of these drugs, and legislation calling for usage only when necessary means that there is no financial incentive for pharmaceutical companies, who prefer to invest in drugs treating chronic illnesses. Governments, foundations, and non-profits need to greatly increase research into understanding these pathogens in order to develop new medicines. In the developing world some progress has been made, with The African Society for Laboratory Medicine being established to improve research into resistance. Despite being predicted to suffer most significantly, Africa currently only offers 2% of the world’s research output, and international investment into improving research infrastructure is needed for the developing world to help abate their future catastrophe.
Poverty causes a multitude of problems for the availability of antimicrobials. The cost of medicine is a significant issue in the developing world; many pharmaceutical companies with monopolies on essential medicines charge exorbitant prices despite low production costs. This means that governments in low-income countries cannot afford to fund treatments for many infections. This leads to the unnecessary suffering of millions, and the development of resistance through the use of poorly suited antimicrobials that may be the only available option. Further, the cost and lack of availability of these medicines is a significant motivator for the sale of cheaper counterfeits. Low-income governments are not capable of controlling counterfeit drugs and enforcing penalties for their sale, allowing black market medicines to flourish. The African Medicines Regulatory Harmonization has been created to provide safe, effective, and affordable medicines in Africa, but a greater allocation of resources is needed to confiscate illicit medicines, enforce penalties for selling without a license, and remove financial barriers to access for the general population in order to dismantle the black market.
Misinformation and education of the public remains a key issue to be addressed; a change in attitudes, both in the developed and developing world, is needed. However, the developing world has greater barriers of illiteracy and access to information, meaning that specific education programs are required. During the height of the AIDS epidemic, education programs for journalists about providing information to the public were instrumental in the fight against HIV. A similar approach to resistance will likely be valuable in disseminating accurate information and shaping the public’s attitude toward the use of antimicrobials. Education for healthcare providers and pharmacists is equally vital for correctly dispensing medicines, but also as the primary source of knowledge in educating their patients and the wider community. Both governments and international aid organizations share a responsibility to educate communities, encourage responsible antimicrobial use, and conserve the lifespan of our essential medicines.
The control of antimicrobial resistance is our global responsibility. Governments across the world need to recognize resistance as a public health emergency, enforce legislation in their own countries to regulate the use of antimicrobials, and offer aid, resources, and knowledge to developing countries to help them combat resistance. Without effective antimicrobials, modern medical procedures like surgery and chemotherapy will soon be a thing of the past. As we look to protect the world from threats like climate change, we too must fight antimicrobial resistance for future generations. Otherwise, the next generation of humans will be crippled by disease, undue suffering, and potentially wiped out by pandemics at the hands of the next generation of superbugs.
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