“Human resistance to antibiotics could bring ‘the end of modern medicine as we know it’,” according to The Daily Telegraph. The newspaper says that we are facing an antibiotic crisis that could make routine operations impossible and a scratched knee potentially fatal. Similarly, the Daily Mail’s headline stated that a sore throat could soon become fatal.
The alarming headlines follow a new report by the World Health Organization (WHO , which set out ways to fight the growing problem of antimicrobial resistance (AMR . AMR occurs when infectious organisms, such as bacteria and viruses, adapt to treatments and become resistant to them. The publication specifically addressed the long-known problem of antibiotic resistance, where increasing use of antibiotics can lead to the formation of “superbugs” that resist many of the antibiotic types we currently have. It outlined a variety of measures that are vital for ensuring we can still fight infections in the future and described how other major infectious diseases, such as tuberculosis, HIV, malaria and influenza, could one day become resistant to today’s treatment options.
However, despite the future danger posed by antimicrobial resistance, the situation is not irretrievable. As Dr Margaret Chan, director general of WHO, said: “much can be done. This includes prescribing antibiotics appropriately and only when needed, following treatment correctly, restricting the use of antibiotics in food production to therapeutic purposes and tackling the problem of substandard and counterfeit medicines.” The report also highlighted successful cases where antimicrobial resistance has been tackled, demonstrating that we can safeguard the effectiveness of important antimicrobial medicines with dedicated, rational efforts.
Where has the news come from?
WHO has just published a new report (“The evolving threat of antimicrobial resistance - Options for action” that sets out a global strategy for fighting antibiotic resistance. It explores how over past decades, bacteria that cause common infections have gradually developed resistance to each new antibiotic developed, and how AMR has evolved to become a worldwide health threat. In particular, the report highlights that there is currently a lack of new antibiotics in development and outlines some of the measures needed to prevent a potential global crisis in healthcare.
This is not the first time WHO has set out such a strategy. In the 2001, WHO published its “Global strategy for containment of antimicrobial resistance”, which laid out a comprehensive list of recommendations for combating AMR. The current report looks at the experiences over the past decade of implementing some of these recommendations, the progress made, and what else should be done to tackle AMR.
What is antimicrobial resistance?
Antimicrobial resistance (AMR occurs when microorganisms, such as bacteria, viruses, fungi or other microbes, develop resistance to the drug that is being used to treat them. This means that the treatment no longer effectively kills or inactivates the microorganism. The term “antimicrobial” is used to describe all drugs that treat infections caused by microorganisms. Antibiotics are effective against bacteria only, antivirals against viruses, and antifungals against fungi.
The case of penicillin illustrates the AMR phenomenon well. When penicillin was first introduced in the 1940s, it revolutionised medicine and was effective against a wide range of staphylococcal and streptococcal bacteria. It was also able to treat infections that had previously been fatal for many people, including throat infections, pneumonia and wound infections. However, with increasing use of antibiotics over the decades, bacteria began to adapt and develop changes in their DNA that meant they were resistant to the actions of the once powerful antibiotic. These bacteria would survive and proliferate, which meant their protective genes would then be passed on to other strains of bacteria. As a result, new and stronger antibiotics had to be created to combat the resistant bacteria.
AMR is driven by many factors, including overuse of antimicrobials for human and animal health and in food production, which can allow microbes to adapt to antimicrobials they are exposed to. Poor infection-control measures, which fail to prevent the spread of infections, also contribute. In particular, the WHO publication reports what it describes as the five most important areas for the control of AMR, as recognised in its 2001 strategy:
- surveillance of antimicrobial use
- rational use in humans
- rational use in animals
- infection prevention and control
- innovations in practice and new antimicrobials
How big is the problem?
As the report describes, AMR makes it difficult and more expensive to treat many common infections, causing delays in effective treatment or, in the worst cases, an inability to provide effective treatment at all. Many patients around the world suffer harm because infections from bacteria, viruses, fungi or other organisms can no longer be treated with the common medicines that would once have treated them effectively.
The report presents some startling facts on major infectious diseases worldwide:
- Malaria: malaria is caused by parasites that are transmitted into the bloodstream by a bite from an infected mosquito. Resistance to antimalarial medicines has been documented for all classes of the drug, which presents a major threat to malaria control. The report describes that a change in national antimalarial treatment policy is recommended when the overall treatment failure rate exceeds 10%. Changes in policy have been necessary in many countries due to the emergence of chloroquine resistance. This means that alternative forms of combination therapy have to be used as first-line treatment.
- Tuberculosis: in 2010, an estimated 290,000 new multidrug-resistant tuberculosis (TB cases were detected among the TB cases notified worldwide, and about one-third of these patients may die annually. Inaccuracies in diagnosis also impede appropriate treatment.
- HIV: resistance rates to anti-HIV drug regimens ranging from 10% to 20% have been reported in Europe and the USA. Second-line treatments are generally effective in patients when the first-line therapy has failed, but can only be started promptly if viral monitoring is routinely available.
- Common bacterial infections: various bacteria can cause infections within the chest, skin and urinary tract bloodstream, for example, and the inability to fight these infections appears to a growing problem in healthcare. Estimates from Europe are that there are 25,000 excess deaths each year due to resistant bacterial hospital infections, and approximately 2.5 million avoidable days in hospital caused by AMR. In addition, the economic burden from additional patient illness and death is estimated to be at least ˆ1.5 billion each year in healthcare costs and productivity losses.
What can be done about AMR?
The five key areas that the report highlights could tackle the problem of AMR are as follows:
Surveillance of antimicrobial use
Tracking antimicrobial use (in particular antibiotic use and looking at the emergence and spread of resistant strains of bacteria is a key tactic in the fight against AMR. This can provide information, insights and tools needed to guide policy and measure how successful changes in prescribing may be. This can happen both locally and globally.
AMR is a global problem but, at present, there appears to be wide variation in the way regions and countries approach AMR surveillance. This means there is a long way to go before it can be carried out worldwide.
Rational use in humans
Antimicrobials can obviously be important or even lifesaving in appropriate situations, but it is just as important to prevent unnecessary use of antimicrobials, which can lead to resistance. Putting this into practice worldwide is said to be difficult, but rationalising antimicrobial use has had a demonstrable impact on AMR in some cases.
Rational use in animals
Antibiotics are said to be used in greater quantities in food production than in the treatment of disease in human patients. Also, some of the same antibiotics or classes are used in animals and in human medicine. This carries the risk of the emergence and spread of resistant bacteria, including those capable of causing infections in both animals and people.
The problems associated with the use of antibiotics in animal husbandry, including in livestock, poultry and fish farming, are reportedly growing worldwide without clear evidence of the need for or benefit from it. There are said to be major differences in the amounts of antimicrobials used per kilogram of meat produced in high-income countries, and actions need to be taken by national and international authorities to control this.
Infection prevention and control in healthcare facilities
The hospital environment favours the emergence and spread of resistant bacteria. The report highlights the importance of infection-control measures to prevent the spread of microbes in general, regardless of whether they are resistant to antimicrobials. Many facilities and countries are reported to have progressed well since 2001, implementing many recommendations on infection control and prevention, although gaps and challenges still remain.
Innovations
Lastly, the report describes how innovative strategies and technologies are needed to address the lack of new antimicrobials being produced. As the report says, while antimicrobials are the mainstay of treatment for infections, diagnostics and vaccines play important complementary roles by promoting rational use of such medicines and preventing infections that would require antimicrobial treatment. So far, new products coming on to the market have not kept pace with the increasing needs for improvements in antimicrobial treatment. However, current challenges to new research developments can be both scientific and financial.
Can these strategies really stop AMR?
While AMR poses a significant threat to health in the future, the situation does not appear to be irretrievable. The WHO report and an accompanying press release highlight some examples of success stories over the past years:
- In Thailand, the "Antibiotic Smart Use" programme is reported to have reduced both the prescribing of antibiotics by prescribers and the demand for them by patients. It demonstrated an 18–46% decrease in antibiotic use, while 97% of targeted patients were reported to have recovered or improved regardless of whether they had taken antibiotics.
- A pharmacy programme in Vietnam reportedly consisted of inspection of prescription-only drugs, education on pharmacy treatment guidelines and group meetings of pharmacy staff. These measures were reported to give significant reduction in antibiotic dispensing for acute respiratory infections.
- In Norway, the introduction of effective vaccines in farmed salmon and trout, together with improved fish health management, was reported to have reduced the annual use of antimicrobials in farmed fish by 98% between 1987 and 2004.
- In 2010, the University of Zambia School of Medicine was reported to have revised its undergraduate medical curriculum. AMR and rational use of medicines were made key new topics to ensure that graduates who enter clinical practice have the right skills and attitudes to be both effective practitioners and take a role in fighting AMR.
How can I help?
There are times when antibiotics are necessary or even vital. However, as patients and consumers, it is important to remember that antibiotics or other antimicrobials are not always needed to treat our illnesses, and we should not expect them in every situation.
For example, the common cold is caused by a virus, which means it does not respond to antibiotics. However, people may expect to be given antibiotics by their doctor when they are affected, even though they offer no direct benefit and could raise the risk of bacteria becoming resistant. Furthermore many common viral and bacterial infections such as coughs, throat and ear infections and stomach upsets, are “self-limiting” in healthy people, which means they will generally get better with no treatment at all.
If, on the other hand, you are prescribed an antimicrobial, it is important to take the full course as directed. Taking only a partial course of an antimicrobial may not kill the organism but may expose it to a low dose of a drug which can then contribute to resistance.
Links To The Headlines
Health chief warns: age of safe medicine is ending. The Independent, March 16 2012
Resistance to antibiotics could bring "the end of modern medicine as we know it", WHO claim. The Daily Telegraph, March 16 2012
Why a sore throat could soon be fatal: Bugs are becoming more resistant to antibiotics, warn health chiefs. Daily Mail, March 16 2012
Links To Science
WHO: The evolving threat of antimicrobial resistance - Options for action. March 16 2012
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JUDY WOODRUFF: A short time ago, a U.S. government official identified the U.S. soldier accused of killing Afghan civilians as Army Staff Sgt. Robert Bales.
And on that, we turn the analysis of Shields and Brooks. That is syndicated columnist Mark Shields and New York Times columnist David Brooks.
Welcome, gentlemen.
This is the first time we have the name.
We knew 38-year-old staff sergeant. He is being blown tonight from Kuwait to Fort Leavenworth, Kan.
David, this terrible incident, the killing of all these civilians by -- and he is the suspect alleged to have done this -- how does it change what the U.S. is trying to do in Afghanistan?
DAVID BROOKS: Well, I'm not sure it will have a long-term effect.
There have been tragedies before. There have been drone killings. There have been a lot of civilian killings over the years. And, as Ryan Crocker said, generally, we have been through them.
I think what is different now is the circumstances surrounding this and the Quran burnings, which is that we're much closer to the exits. We're certainly leaving by 2014. A lot of people now think we should leave by 2013. And so that idea that the exits are so close creates this momentum where people think, let's get out of here.
And what you have is a lot of Afghan capital is leaving the country, waiting for what is going to happen next. You have got an Afghan -- the educated class leaving the country and applying for asylum abroad, citizenship abroad. You get the Taliban knowing we don't have much longer to wait. So they are much more suspicious about negotiations.
So what happens is, when you begin the withdrawal process, you get this spiral. And so managing the withdrawal -- we're all agreeing we're going to withdrawal -- becomes much, much more difficult for the U.S.
JUDY WOODRUFF: So, Mark, is it all about just managing the withdrawal and getting out faster?
MARK SHIELDS: No, I think it's more than that, Judy.
I think, first of all, there's an iron rule of history here. And that is that armies of occupation throughout human history are unpopular. Just think of the French, who were indispensable to the American Revolution, had stuck around for six months. Americans would have been stoning them in the streets. That's just -- that's human nature.
I think that is the first reality. Now this war is 10 years old. Secondly, nobody can define what the mission is now. Managing the exit, I mean, is this for the more expenditure of blood and treasure and Americans risking death, and worse?
And I guess that -- I think that is where it is. And I think that is the reality. It's got a political implication now. This week, we saw Newt Gingrich say it wasn't -- Afghans -- was not doable, Afghanistan was not doable, Rick Santorum saying that we ought to double the resources -- I'm not sure what resources mean -- or begin to pull out or accelerate the pullout.
And it really appears to be more of a political problem than a strategic international problem.
JUDY WOODRUFF: But. . .
DAVID BROOKS: I have to say, I disagree with that. I think we know what the mission is.
The military is very clear about this and the president has been very clear about this, is that we are trying to create an Afghan army that can defend the country, so it doesn't descend back into civil war, so it doesn't descend back into a pre-9/11 circumstance.
And the people in the military, who are not particularly political, think that is quite doable. And they are little disturbed by the talk of the early withdrawal, because they think they can do that and we can get out. The Afghan army has -- is the one sole institution in that country which sort of functions. It's not perfect by any means. A lot of the troops are illiterate, among other things.
But it does sort of function and there are a lot of them. And so there is some expectation that you will be able to create an army so you won't have a long civil war, as you had after the Soviet pullout, after -- in previous pullouts.
JUDY WOODRUFF: So you don't see that as. . .
MARK SHIELDS: No, I stand second to nobody in my admiration of the military, but there is a pattern of American generals. they are always reluctant to go into a war and they are always to leave it. That is the pattern. And that is what we're seeing now, because this is a failed mission.
Let's be very blunt about it. We are not going to leave Afghanistan as a functioning, operating society. Karzai is a disaster. If you can remember -- those who remember South Vietnam, this is the parallel, this is the bookend to that. We are propping up a corrupt regime that doesn't have the respect and commitment of its own people and it has no commitment and respect of its people. That is the reality. He is the mayor of Kabul at best. And that. . .
JUDY WOODRUFF: So when the ambassador, Ryan Crocker, tells Jeff, as he did a few minutes ago in that interview, that considering the circumstances,
Hamid Karzai is doing what he has to do. . .
MARK SHIELDS: He is, what, playing to the gallery by insulting Leon Panetta and condemning the United States and chastising us and telling us what our strategy ought to be there? I just -- I don't see that he is a particularly either admirable or reliable ally.
DAVID BROOKS: I agree with that. I don't have much -- Ryan Crocker has to say he has a lot of room for Hamid Karzai.
I don't think too many people -- certainly, the U.S. military doesn't. They see him as corrupt, or at least his brother as corrupt. They see a lot of corruption rife through Afghanistan. There's no question about that.
But what we want is just stability so we won't have the Taliban coming in kicking girls out of school. You won't have just a long civil war, which will be a breeding round for Taliban, which will then bleed over into Pakistan. That's what we want.
And so can we get some basic level of stability? Well, I think the generals, maybe they're too yahoo about this, but I do think they think it's possible. And we have handed over large parts of Afghanistan to Afghan control. They're running it without really U.S. troops. We're busy in the south and other regions. So there is some just basic stability. That is all we want.
JUDY WOODRUFF: Mark, you mentioned the political -- the implications in the election this year. Do you see any? Do you see this having an effect one way or another?
DAVID BROOKS: Newt Gingrich said what he said for a reason. People are exhausted by this.
And if you ask them, should we stay in Afghanistan, no, we should spend our money here. That's what people will tell you. On the other hand, I'm not sure it will be a huge campaign issue, because the fiercest opposition to being there is in the Democratic Party. And they're not going to go against the president.
JUDY WOODRUFF: Ron Paul.
DAVID BROOKS: And Ron Paul.
JUDY WOODRUFF: And Ron Paul.
DAVID BROOKS: And Ron Paul, exactly.
MARK SHIELDS: I think it's beyond partisanship now, I think, the American fatigue with Afghanistan and the lack of enthusiasm for the United States continuing to fight and die there.
Stability is a -- that is not exactly unconditional surrender. We want to leave stability in our wake. That just doesn't -- I don't think it's a rallying cry. I don't think it's a defining mission that Americans are going to support at this point.
JUDY WOODRUFF: Okay.
The campaign, David, where does it stand? Mitt Romney, we thought he had a shot in Mississippi and Alabama.
Rick Santorum won. Newt Gingrich is still in the race. Where is it? Where are we?
DAVID BROOKS: From one quagmire to another.
The good news is we are nearly halfway done the campaign, not quite. It will go on. And it's just -- I don't think Romney is not going to get the nomination. I think he will get the nomination, because if you look at the delegate math, A., he is way ahead, B., he is likely to stay way ahead.
Will he get enough delegates to clearly give him the nomination? That, I'm not sure of, but I think he will be close. And I say that because what has happened in campaign after campaign or in state after state is purely the battle of demographics, upscale voters, middle-class voters going for Romney, especially urban voters, downscale and rural voters going for Santorum.
Henry Olsen of the American Enterprise Institute points out that in every place where there is a Major League baseball park, Romney carries that place. In every place where there is a AA minor league team, Santorum carries that place.
It's been purely demographic. And if you count the demographics going forward to all these other states, the Californias and even Illinois, there are just more Romney people. So you would expect him to finally get the nomination, after an incredibly brutal and terrible slog.
JUDY WOODRUFF: So is it inevitable?
MARK SHIELDS: I don't think inevitable.
JUDY WOODRUFF: Or almost.
MARK SHIELDS: A week is a lifetime in politics, and five months an eternity.
I still would bet on Mitt Romney. We are moving -- now, David is right -- we are moving into territory now, Delaware, Maryland, New York, Connecticut, Wisconsin, Illinois, that are better Romney states than they are Santorum states.
What Santorum has achieved is rather remarkable, outspent, outgunned, without any establishment endorsement, written off, just ignored in all those early debates. And contrary to all of the prevailing conventional wisdom about American politics in 2012, he got 49 percent of white working women who work outside of the home voting for him. It's just -- it's an achievement.
JUDY WOODRUFF: Despite all the controversy.
MARK SHIELDS: And he has got the passion. Romney has got the deep pockets. Romney has got the organization. He has got the enthusiasm. That's really. . .
DAVID BROOKS: I must say, I think Romney has a much, much, much better chance in the fall.
It's hard not to be impressed by what Santorum is doing. He's being outspent 15-1 in some places.
MARK SHIELDS: That's right.
JUDY WOODRUFF: Well, what reward does he get then? He just keeps fighting and. . .
MARK SHIELDS: Well, if he could get Gingrich out of the race, he could finally get Romney one-on-one. But Gingrich -- what are the chances of getting Gingrich out?
A man who says -- and on the record -- that "I define my job as saving Western civilization" is not somebody who probably is going to be talked out a race.
JUDY WOODRUFF: I hate to remind you of this, but
on this program last week, you said, if Newt Gingrich doesn't win Alabama and Mississippi, he's going to have to get out.
MARK SHIELDS: Yes, he is going to have to get out.
JUDY WOODRUFF: It's now a week later, Mark.
MARK SHIELDS: That just shows you how limited logic is.
(LAUGHTER
MARK SHIELDS: No. But, I mean, it just -- he really -- now he is saying, "I want to go to Tampa and be a player."
There is a hell of a reason to make phone calls and go door-to-door.
DAVID BROOKS: Right. He thinks he can deny Romney the delegates. And it's possible he can.
MARK SHIELDS: Yeah.
DAVID BROOKS: One of the interesting parlor games, I guess, if Gingrich doesn't get out is, what would happen if he did get out?
Some of the polls show the Gingrich voters are kind of split between Romney and Santorum. It's not necessarily they will all go to Santorum. I think most of the polling suggests the majority would go to Santorum.
JUDY WOODRUFF: But, for now, you see this thing going on?
MARK SHIELDS: It would have been the difference in Ohio and Michigan.
DAVID BROOKS: That's right. It could -- literally, we're not halfway through.
JUDY WOODRUFF: The last thing I want to ask you about is this column, op-ed piece in The New York Times by this former -- now former trader at Goldman Sachs, just blistering,
about the culture of Goldman Sachs, saying it's all about the money.
We knew it was about the money, but he's saying putting the company ahead of the customer.
MARK SHIELDS: Well, Judy. . .
JUDY WOODRUFF: Is this a surprise? What does it tell us?
MARK SHIELDS: This wasn't a column written about the Salvation Army that takes care of homeless and poor people or a column written about the Little Sisters of the Poor who take care of the indigent and dying.
This was a column written
about Goldman Sachs. And people are ready to believe about Goldman Sachs. Understand this in American polling. When you ask favorable of institutions, big corporations rate higher, big pharmaceutical companies, health insurance companies, the Congress of the United States rates higher in favorability than does Wall Street and financial institutions.
And this is a group conspicuous for its arrogance and for total self-absolution of its own responsibility in any way for the financial crisis in this country and the suffering that followed in its wake. And to be very blunt about it, this is a company that created a financial instrument and sold it to its customers solely because a hedge fund customer, larger customer, wanted to bet against it. And they made millions on that.
So are people ready to believe it? Yes, they are ready to believe it.
JUDY WOODRUFF: So, stating the obvious, in 20 seconds. . .
DAVID BROOKS: Well, yeah.
I mean, I thought the guy who wrote it was a bit narcissistic, talking about what a great guy he was. It was three-quarters about him. Nonetheless, the decline in manners and ethos, where people at firms like that talk about their own clients as if they're to be their cows to be milked, I do think that is true. And that is what needs to be addressed.
JUDY WOODRUFF: Well, we thank you both, David Brooks, Mark Shields.
MARK SHIELDS: Thank you.
