BRIGHTON – Existing anti-microbial drugs are becoming ineffective. If current trends continue, we could end up reliving conditions before the discovery of antibiotics, when infectious diseases were major killers.
Meeting the challenge of drug-resistant microbes will be difficult. It will require not only major investments in research and development of new anti-microbial drugs, but also a system to control and restrict new treatments, in order to preserve their efficacy. As with the response to climate change, an effective strategy will require international coordination. In particular, the needs of pharmaceutical companies must be reconciled with those of government payers and the global poor.
Indeed, engaging the poor will be crucial to any effort. Low- and middle-income countries are an important source of drug-resistant organisms. Crowded housing, poor sanitation, and compromised immune systems, whether owing to malnutrition or chronic infections such as HIV, provide fertile ground for contagion. Antibiotics are often misused or low-quality, providing bacteria the opportunity to develop resistance. Large volumes of antibiotics are also used in animal husbandry. Meanwhile, greatly improved transportation infrastructure – between rural and urban areas and between countries – means that resistant genes quickly become part of a global pool.
In many vulnerable countries, the government health-care system cannot meet demand, and a variety of providers are attempting to bridge the gap. These range from medical specialists to informal providers, who work largely outside the regulatory framework. These patchwork systems do have benefits. A recent study in Bangladesh, for example, concluded that antibiotics provided by so-called “village doctors,” often operating from market stalls, contributed to declines in mortality from post-natal sepsis and childhood pneumonia. But there is also considerable evidence that the drugs being provided are of varying quality and are frequently taken unnecessarily. Too often, patients do not purchase a full course of treatment.
One response could be to enact and enforce laws that make antibiotics available only on a doctor’s prescription. However, this could end up severely limiting poor people’s access to antibiotics, leading to higher death rates from infections, making it politically unacceptable and thus difficult to enforce. A better alternative would be to develop new strategies to improve antibiotic treatments that are provided through informal channels.
For starters, investment is needed to generate reliable surveillance data on the drugs that are effective against common infections. Treatment guidelines must incorporate this information and be given to all providers of antibiotics.
Meanwhile, high-quality antibiotics must be made available at affordable prices. Counterfeit products must be identified and removed from the marketplace, and a regulatory partnership between governments, the pharmaceutical sector, and citizens’ groups must be developed to control for quality. Prices must be kept low through bulk procurement; in some cases, public subsidies may be necessary.
Measures to reduce prices will need to be complemented by efforts to discourage overuse. Innovations in packaging, perhaps providing full courses of appropriate combinations of drugs, could simplify treatment decisions. Likewise, development of low-cost diagnostic technologies could help diminish the need to provide treatment on the basis of symptoms alone.
The biggest challenge will be to encourage providers of antibiotics to change their behavior. This will require measures such as accreditation, modification of payment mechanisms, and the involvement of intermediary organizations to give technical support and monitor performance. These organizations could include NGOs, religious organizations, social entrepreneurs, and companies that distribute drugs. These activities are unlikely to be commercially sustainable, and thus will require support from governments, philanthropies, and perhaps drug producers.
In the meantime, the public must receive reliable information and advice on the proper use of antibiotics. This is particularly important where citizens rely largely on their own resources to cope with health problems.
Implementing a system-wide change in the use of antibiotics will require the creation of national and global coalitions. One core aim must be to establish basic standards of conduct for health workers and drug companies that reflect the needs of patients and communities. Governments will need to build their capacity to play an effective role in this process, and companies that develop, produce, and distribute drugs and diagnostic technologies will have to contribute actively to the search for collaborative solutions. Only if we manage antiobiotics in a fair and sustainable way will we be able to benefit from them at all.