Antimicrobial Resistance (AMR)

Medicine covers biological systems on the organismal scale. In public health, social problems meet biological problems on the population scale. In anti-microbial resistance, now we have an evolution problem interacting with all of it. It’s not simple, and there’s no easy solution. With this many interconnected complex systems, we have wicked problems on wicked problems on wicked problems.

Resistance has been a worry since the beginning of antibiotics, but it was considered a problem for innovation and economic forces to solve. Using one complex system (pharmaceutical drug development) to fix another (antibiotic resistance) can backfire strongly , and that’s happened here, leaving us with an increasing number of antimicrobial-resistant (AMR) diseases.

Medical antibiotic use not the whole picture, despite this frame. Discussions of antibiotic use stick to human use of antibiotics, despite widespread use of antibiotics for growth promotion of livestock. In the US, we’ve seen some progress in slowing this use, though not directly stopping it — in 2013, the FDA requested that pharmaceutical companies stop selling antibiotics to farmers for growth promotion purposes , but explicitly continued to allow them for disease prevention purposes. There is some hope that economic pressures will step in where regulation is insufficient here, as McDonald’s and Tyson Foods are both breaking away from chicken produced with human antibiotics by the end of this year.

The issue is, unfortunately, a good deal wider than that in multiple directions. The United States is far from the only country using antibiotics in livestock, and chicken is far from the only meat produced with antibiotics for growth promotion. A 2015 study found e. coli resistant to last resort antibiotic colistin in 21% of pigs in slaughterhouses and 15% of raw pork and chicken meat, possibly due to its widespread use in China and other countries.

With an economic focus, we could ask why antibiotics are so affordable for growth promotion in agriculture while epi-pens and insulin are so expensive for humans. With a medical focus, we can look into prescribing antibiotics only when it’s appropriate. With a global health focus, we bring these together and look for solutions that take into account imports and exports of livestock/meat along with differences in antibiotic availability and need in low and middle income countries as compared to higher-income countries.

A comprehensive review of the current issues in anti-microbial resistance came up with ten recommendations:

  1. Improvements in sanitation
  2. Surveillance of antibiotic use and drug resistance
  3. Reducing antibiotic use in livestock
  4. Improving diagnostic tools, so as to minimize inappropriate antibiotic use
  5. Public awareness of proper antibiotic use
  6. Prevention-centric alternatives, including vaccines
  7. Making infectious disease a better sector to work in
  8. Market entry rewards for new antibiotics
  9. Research innovation fund
  10. Building a global AMR coalition

These solutions are building off a global “one health” view: global approach, across animal and human, all countries working together to improve global health. Wellcome’s review includes the following:

“AMR is a profound threat to human and animal health that will require transformational change across medicine, agriculture and the environment. Summit participants identified a range of practical policy interventions to inform the development of National Action Plans for AMR. Different countries are at different stages in the journey towards effective response strategies, and should select policy interventions most appropriate to their circumstances, while building their capabilities over time.”

This is where we stand going in to the whole-day meeting of the General Assembly of the United Nations focused on anti-microbial resistance. I am watching today at http://webtv.un.org/live/ to see the discussion of this truly global issue.