By Annie Wilkinson
This week was World Antibiotic Awareness Week which is likely the reason that I woke up to my radio alarm informing me that 7 per cent of gonorrhoea cases in Toronto are now untreatable. If that wasn’t bad enough scientists have discovered a mutated bacterial gene which is resistant to a ‘last resort’ antibiotic (colistin) and which can – and has – spread to other strains and species of bacteria. The discovery raises the prospect of a ‘post-antibiotic era’ where we are susceptible to epidemics of untreatable infections and where modern medical procedures such as surgery or chemotherapy - which rely on antibiotics to treat associated infections - are no longer safe.
The challenge has been compared to climate change. Prime Minister, David Cameron, warned of a return to the ‘dark ages of medicine’. President Barack Obama has made drug resistance a priority in the USA’s Global Health Security Agenda. As drug resistant pathogens do not respect national borders, the World Health Assembly adopted the ‘Global Action Plan on Anti-microbial Resistance’ (AMR). Experience suggests there is a risk these aspirations will be undermined by gaps between policy statements and real-world governance.
How can we address antibiotic resistance? Antibiotic resistance is a multi-sectoral problem involving the use of antibiotics in human and animal health systems, and the two way exchange of resistant bacteria between these systems. As should be expected for such a complex problem, there are no easy solutions. A Lancet series, also published this week, provides a good overview of what we know so far and what has or could help to reduce resistance – integrated human-animal ‘One Health’ approaches, global commitments and coordination, improved surveillance, tighter controls on prescription, improved diagnostics, and disease prevention strategies such as vaccines, are just a few.
However the suite of options also reveals some gaps in knowledge, especially in the regulation of private and informal healthcare providers in the highly marketised health systems in low and middle income countries – where conditions for the development of resistance are especially problematic (pdf). Many of the solutions imply strong states and well-ordered global health and pharmaceutical sectors. This is far from the reality for the large proportion of the world’s population who live in countries with human and animal health systems, comprised of multiple providers and multiple traditions of medicine. A major challenge in these settings is that health provider and drug seller livelihoods are often tied to the sale of pharmaceuticals, including antibiotics.
Working across sectors to tackle AMR Nevertheless, as the Lancet series notes, there a few promising approaches for reducing inappropriate drug use at the community level in such contexts, for example the Integrated Community Case Management (ICCM) of common infections. As highlighted at a panel organised by the Health Systems Global Thematic Working Group on the private sector, private drug vendors showed high rates of compliance with ICCM treatment guidelines despite market incentives encouraging them to sell antibiotics. More strategies which work in the private sector are badly needed. But we also need to think about what prevents more promising initiatives like this being developed, or being widely adopted.
In many contexts official rhetoric on informal providers (e.g. ‘quacks’ ‘charlatans’ and ‘unskilled’) belies the fact that the informal private sector is often the major supplier of health services to poor people. Not to mention they are often highly linked into formal systems through shadow supply and referral networks. In Bangladesh, drug companies cultivate relationships with informal drug sellers, sometimes offering sales incentives. However, institutional resistance to these providers makes it harder to engage the sector. For example when rapid diagnostic tests were provided to private drug sellers in Uganda, formal public sector workers reacted negatively as it was perceived as a threat to their authority and position.
In a report we produced earlier this year on addressing antibiotic resistance in pluralistic health systems (pdf), we argued that alongside strategies such as better surveillance and improved diagnostics there was a need to focus on partnerships and coalition building. This is especially important between the public and private sector, and the formal and informal sector. We have a long way to go in understanding the dense webs of politics and people which antibiotic supply and demand is embedded in. Truly sustainable and effective stewardship of antibiotic use will come from research which elucidates these relationships, and which builds interventions which negotiate the interests of the actors involved.