Opinion: Resistance could pose the greatest threat to our health

On November 18th, 2020, a debate article by The Foundation to Prevent Antibiotic Resistance was published in one of Sweden’s major daily newspapers Svenska Dagbladet. Below follows a translation of the article:

Antibiotics that work are crucial for our ability to provide both advanced healthcare and routine procedures. Hundreds of thousands of people around the world are already dying from resistant infections every year.

World Antimicrobial Awareness Week, a global campaign to raise awareness of the challenge of antibiotic resistance, starts on 18 November. Antibiotic resistance is a serious threat which in the shadow of the covid-19 pandemic is beginning to undermine our modern healthcare. Antibiotics that work are crucial for our ability to provide both advanced healthcare and routine procedures – everything is at stake from cancer treatments to C-sections. Hundreds of thousands of people around the world are already dying from resistant infections every year and this number is expected to reach millions within a few decades.

In order to counter this alarming development, we need to ask two questions: What and who. Firstly, what can be done to effectively slow the development of resistance? And secondly, who can do what is needed?

If we start with what, it is worrying that work against antibiotic resistance is still heavily focused on the development of new antibiotics. In the middle of the 20^th century, the “golden age” of antibiotics, this actually looked like a winning strategy. New antibiotics were developed in quick succession. When an older version proved ineffective, the new medicines could be phased in. However, this throwaway culture has run into problems. It has become increasingly difficult and increasingly expensive to develop new antibiotics. Part of the problem is related to financial incentives – it is simply not profitable to develop drugs that must be used sparingly. This explanation, however, is only half the story. The other half is that we have already picked the low-hanging fruit and now it is technically increasingly difficult to develop new antibiotic drugs. The most recent new class of antibiotics that made it all the way to approved drugs was discovered in 1987 – more that 30 years ago.

If we continue to focus on trying to “beat” the bacteria by developing new antibiotics, then we face an impossible task. The bacteria have evolution on their side. The idea that we could develop new antibiotics faster than the bacteria develop resistance is clearly unsustainable and it also means that we damage the bacteria that we need to function normally and feel well.

Instead, we advocate a dramatically increased focus on preventive work, initiatives that can slow down and control the development of resistance. Instead of running faster, we need to take a step back and make better use of the resources we have. We need to decrease unnecessary and incorrect antibiotic use – not just locally in Sweden and the Nordics, but also in the places where the problems are greatest. Above all, we need to adopt a long-term approach to preventing infectious diseases and the spread of infection in general. This means working proactively with healthcare and not just reactively with medical treatment. We need more cross-disciplinary research to understand what interventions are not just technically possible, but also practically effective in achieving the necessary changes in behaviour. We also need more research on which factors are most crucial for slowing down the development of resistance so that we can prioritise better.

There is no doubt that we will also need new antibiotics, preferably with totally new mechanisms of action. But if we do not learn to use antibiotics responsibly, we are just pouring more water into a leaky bucket.

So who should take responsibility for achieving this in the middle of an escalating pandemic?

Today, much of the responsibility rests with public, governmental and intergovernmental organisations such as the Public Health Agency and WHO. Public health agencies and their equivalents in other countries work locally. Sweden is prominent in this field, but antibiotic resistance is not an issue that can be solved at a national level. Just like the climate question, this is a global challenge. That we take responsibility for our antibiotic use in our corner of the world is a good thing, but it does not solve the wider problem. The WHO on the other hand is the natural international organisation to handle this issue and they do a good job, but their resources are very limited. The total budget of the WHO is less than the Stockholm Region spends on healthcare and antibiotic resistance is just one of many issues they work with. Covid-19 and the rise of global poverty that follows in the wake of the pandemic aggravates the situation still further.

Our conclusion is that the responsibility for work with antibiotic resistance needs to broaden, in a similar way as has happened with the climate issue. This in no way implies a reduced need of initiatives from governments and international organisations, but we must realise that what they can achieve is not enough. If we are to preserve and develop modern healthcare, we also need to mobilise the rest of society – individuals and civil society and meaningful commitment from the private sector.

Earlier this year AMR Action Fund was launched, an alliance of private corporations and philanthropic organisations promising a billion dollar investment for the development of new antibiotics. This is very good news, but for new antibiotics to work in the long run we also need to broaden the responsibility for preventive work that can curb the development of resistance in a strategic and effective manner.

Just as the climate threat requires both new solutions for how to live on a warmer planet and initiatives to slow down global warming, the resistance threat requires both new antibiotics and a slowdown of resistance development. Governments cannot solve the climate crisis without support and collaboration from the private sector and civil society; the same holds true for the antibiotic resistance crisis.