Can International Diplomacy Help Combat the World’s Superbugs?
In a meeting of the UN General Assembly on Wednesday, world leaders committed to toughening regulation of antimicrobials and encouraging development of new antibiotics and treatments, among other measures. The agreement was an exceptional move for the group, which has only taken up three other health issues in the past — HIV, non-communicable diseases and Ebola.
Antimicrobial resistance happens when bacteria, parasites, viruses and fungi adapt to drugs previously used to combat them — and globally, the problem is growing. In 2014, researchers in the UK estimated that 700,000 people worldwide die of drug-resistant infections each year, and that the death toll could climb to 10 million people annually by 2050 — claiming even more lives than cancer and diarrheal diseases do now.
Of the many forms that antimicrobial resistance takes, health officials are particularly concerned about growing resistance to the antibiotics that treat everything from common STIs to urinary tract infections, pneumonia and tuberculosis.
But even a freshly inked agreement at UN headquarters may not kill a question that many have been asking since the meeting was put on the books. Namely, how much can a political body like the UN — usually focused on economics and international security — do to halt superbugs?
Laura Kahn, a physician and research scholar at Princeton University, says actually, international cooperation is our best shot at fighting antibiotic resistance. That’s because the causes of antibiotic resistance are rooted in issues like the global economy, food security and the environment.
“For us, antibiotics are the foundation of modern medicine, but we can’t forget that agriculture, and the food security that it provides, is the foundation of civilization itself,” Kahn says. “And so for a lot of countries that don’t have food security, they still have many, many hungry people. And let’s not forget that the United States has some hungry people too. This is a really difficult balancing act — between figuring out whether or not we can feed ourselves sustainably and still have our antibiotics, too.”
Kahn says along with the US, the world’s top total users of antibiotics are India and China. Of the approximately 1 billion people worldwide who lack access to public sanitation, 600 million live in India, where open defecation has led to high rates of diarrheal diseases, malnutrition and other ailments. As a result, antibiotics — available over the counter in India — are in frequent use, leading to what Kahn calls “some of the most resistant bacteria in the world.”
And in China, where some of the world’s largest pig farms feed the world’s largest population, researchers have gotten a crash course in how our widespread use of antibiotics in animal husbandry is changing the environment. Kahn says one study found that antibiotic-resistant gene residues in the manure of large Chinese swine farms were up to 28,000 times greater than levels at farms that don’t use antibiotics.
“And of course, all of this manure gets into the soil and the waterways and the coastal waters,” Kahn says. “Ultimately, we are altering the global resistome in ways that we don’t understand. Many of the antibiotics that we have come from soil bacteria, and so by placing all of this manure with increased levels of antibiotics and resistance genes [in the soil], resistant bacteria mixes in with the soil microbes. It’s not good.”
Using metagenomics, scientists have extracted DNA directly from soil and discovered antibiotic resistance genes all over the world.
“They’re in the Arctic permafrost, they’re in Antarctic lakes,” Kahn says. “They appear to be ancient and everywhere. And by blasting the environment with all of our antibiotic use, we are increasing the expression of these genes.”
But if anything, Kahn says, the spread of antibiotic resistance in the environment underscores the need for a coordinated effort like the UN’s to address the issue — with solutions ranging from improving public sanitation to encouraging development of antibiotic alternatives.
“It’s a major global problem, involving humans, animals, and the environment,” Kahn says. “I just want to put a plug in to the ‘one health’ concept, and this is the simple concept that human, animal, and environmental health are linked. And because they are linked, we must address complex issues such as antimicrobial resistance in an interdisciplinary way. That’s the only way we can do it.”
Laura Kahn is a physician and research scholar for the Program on Science and Global Security at the Woodrow Wilson School of Public and International Affairs at Princeton University.
IRA FLATOW: This is Science Friday. I’m Ira Flatow. Doctors and public health officials have been warning us for a while now about the spread of antibiotic-resistant bacteria, you know, superbugs. But as with most things, it’s taken politicians a while to catch on.
Well, things have finally gotten scary enough for world governments to meet to take action. Next week, the UN will meet in New York to discuss antibiotic resistance. And presumably, delegates will discuss scaling back the unnecessary use of antibiotics on animals and humans in countries around the world.
Now, why is this necessary? And what would an agreement– what might it look like? With me to discuss these questions is Laura Kahn, a physician, a research scholar at Princeton University, and author of the book One Health and the Politics of Antimicrobial Resistance. Dr. Khan, welcome to Science Friday.
LAURA KAHN: Thank you so much, Ira.
IRA FLATOW: Well, we’ve been talking about this stuff, antibiotic resistance, for years. Why finally is the UN now meeting to discuss it?
LAURA KAHN: Well, the World Health Assembly met in May 2015 to deliberate on this issue. And they realize that it is much broader than just human health. It involves animals, agriculture, the environment. And they realized that it needed a political input. So they moved it up to the UN General Assembly.
IRA FLATOW: So it’s become such an important issue that politicians are finally getting involved in the use of antibiotic-resistant drugs?
LAURA KAHN: At the global level, yes.
IRA FLATOW: Are there differences in opinion among the countries meeting next week when it comes to this issue?
LAURA KAHN: Well, certainly. The poor developing countries are concerned and justifiably so about feeding their people. So for developed countries, like the United States, more concerned about anti-microbial resistance. We don’t have concerns about food security at this point.
So for us, antibiotics are the foundation of modern medicine. But we can’t forget that agriculture and the food security that it provides is the foundation of civilization itself. And so for a lot of countries that don’t have food security, that they still have many, many hungry people– and let’s not forget that the United States has some hungry people too– this is a really difficult balancing act between figuring out whether or not we can feed ourselves sustainably and still have our antibiotics too.
IRA FLATOW: So some countries are more concerned about feeding their people than worrying about the use of antibiotics at this point?
LAURA KAHN: Seemingly, yes.
IRA FLATOW: Who are some of the worst offenders when it comes to overusing antibiotics? I’d imagine that the US is high up on that list.
LAURA KAHN: That’s right. Well, India, China, and the United States are the top three users totally in use of antibiotics. Now, of course, India and China have over a billion people each. But both have specific challenges that they face.
So for example, according to UNICEF, of the 7-plus billion people on the planet, there are about 1 billion who are openly defecating, meaning that they’re going out to a field, squatting, and doing their business. And of this 1 billion, about 600 million live in India.
So as a result, India has serious disease problems. They’ve got diarrheal diseases, malnutrition, childhood stunting. They have a very high disease burden. And as a result, they are very high users of antibiotics. And not helping the fact is that they provide antibiotics over the counter. So a lot of people just go and stock up on antibiotics. And whenever they feel a little sniffle coming on, they take them. That all increases the resistance of the bacteria. And it shouldn’t come as a surprise that India has some of the most resistant bacteria in the world.
IRA FLATOW: They have–
LAURA KAHN: Now–
IRA FLATOW: I’m sorry, go ahead.
LAURA KAHN: Well, counter that with China– China’s also got to feed a billion people. And they have some of the largest pig farms in the world. They have pig farms of over 10,000 animals. They use antibiotics extensively, because the sanitation’s not so good.
And one study found that antibiotic-resistant gene residues in the manure of these large swine farms are up to 28,000 times greater than farms that don’t use antibiotics. And of course, all of this manure gets into the soil, in the waterways, in the coastal waters. And ultimately, we are altering the global resistome in ways that we don’t understand.
Now, many of the antibiotics that we have come from soil bacteria. And so by placing all of this manure with increased levels of antibiotics and resistance genes, resistant bacteria, mixes in with the soil microbes. And it’s not good. All of this then, of course, gets into the wildlife and particularly birds. They’re flying all over, defecating. They’re spreading resistance genes far and wide.
IRA FLATOW: So I hear what you’re saying is that the manure or the fecal material that people leave behind are the breeding grounds for these superbugs.
LAURA KAHN: Yeah, it certainly doesn’t help. I mean, in addition to taking excessive amounts, we excrete large amounts that gets into the environment. And it helps generate multiresistant bacteria. So it’s a major global problem.
IRA FLATOW: Are we–
LAURA KAHN: Involving– yeah, I’m sorry. I was just going to say, involving humans, animals, and the environment. And I just want to put a plug-in to the one health concept. And this is a simple concept that human, animal, and environmental health are linked. And because they are linked, we must address these complex issues, such as anti-microbial resistance in an interdisciplinary way. That’s the only way we can do it.
IRA FLATOW: Tell me what you mean. How would we address it that way?
LAURA KAHN: Well, we can’t look at just the humans. We have to look at the animal health and the environment. Now, as I had mentioned, the soil bacteria provided a lot of our antibiotics. Now, we don’t know what most of the soil is composed of. We’ve only been able to isolate the soil bacteria. About 1% are able to be grown in the lab. So we really don’t know what’s in the environment.
Now, some scientists have come up with a clever strategy called metagenomics, where they extract DNA directly from the soil. And they don’t unfortunately know exactly what bugs the DNA is coming from. But nevertheless, we’re able to see what’s in that DNA.
And what they discovered is that there are antibiotic resistance genes literally all over the world. They’re in the Arctic permafrost. They’re in Antarctic lakes. They appear to be ancient and everywhere. And by blasting the environment with all of our antibiotic use, we are increasing the expression of these genes. We are altering the global resistomes.
So we need to look at it from that perspective in order– a holistic, interdisciplinary perspective using both medicine, veterinary medicine, agriculture, environmental health. All of these things play into it. It’s not just trying to cut back on use.
IRA FLATOW: What would you hope comes out of this UN meeting?
LAURA KAHN: Well, first of all, it would be very nice if sanitation and hygiene were improved around the world. In the 21st century, no human should be openly defecating. That should be a priority, that you can’t just expect people to cut back on antibiotics if they’re getting sick.
So prevention is, of course, the best medicine. Sanitation 101 is basic public health. And there should be nobody openly defecating. So that’s one thing that I would hope would come out of this, is just to lower the disease burden that so many countries have.
Number two, we need to implement genomic surveillance. And by that, I mean that what we’ve been doing so far up till now is, when we look at these resistant microbes, we are only looking at the resistance genes. And it’s akin to looking at people’s hair color.
So let’s say, for example, I put everybody with red hair on the planet in a large room and try to figure out how they’re related to each other based on their hair color. You simply cannot do it. You need to monitor their genome. You have to see what exactly is in their DNA.
Now, before 2008, the cost of sequencing an entire genome was prohibitively expensive, like over $100,000. Since 2008, the cost of sequencing genomes has dropped markedly, allowing researchers then to include that technique in their surveillance. And hospitals now are just at the very beginning of starting to use this technology. And when you do that, very interesting things come out that is surprising, that not all of these bacterias– you make assumptions of where they’re coming from. But they don’t always act in ways that we assume.
IRA FLATOW: Researchers are saying, maybe if we come up with new vaccines or new kinds of antibiotics, what kind of research is on the cutting edge? I know that you also talk about going backwards to old phage therapies.
LAURA KAHN: That’s right. I’m a big proponent of bacteriophages. Now, certainly vaccines would be an important strategy. And we do have some vaccines against bacterial disease. We need a lot more. I mean, as I said, prevention is the best medicine. And vaccine acts like a boot camp for your immune system.
So if your immune system recognizes the bug and a vaccine is basically weakened or deactivated bacteria or parts of them, it gives your immune system kind of a heads up when it encounters a real one in your day-to-day life.
IRA FLATOW: How much money is being spent on new kinds of drugs? Is it a high priority with the drug companies?
LAURA KAHN: Well, most pharmaceutical companies have gotten out of the vaccine production, because they don’t view it as profitable, similarly with antibiotics too. A lot of them have gotten out of the antibiotic research and development, because it’s not considered profitable.
You only take antibiotics ideally for a couple of weeks, and then you’re cured. Contrast that with drugs that you take for chronic diseases, like high blood pressure or diabetes. In many cases, those are required for a person’s lifetime. So it’s a lot more profitable to do that.
But let me just get back to the bacteriophages. They are tiny little viruses that look kind of like lunar landing modules. They are the most prevalent bioform on the planet, and they are bacteria’s natural foes. And there was a lot of interest in them in the beginning of the 20th century. But when antibiotics came on the scene, they were abandoned.
IRA FLATOW: Well, so you’re saying we should try– run out of time, unfortunately. But you’re talking about going back to bacteriophage therapies.
LAURA KAHN: Yeah, I think that would be a good strategy.
IRA FLATOW: Dr. Laura Kahn, physician and research scholar at Princeton University. One Health and the Politics of Antimicrobial Resistance is her book.