I was seven years old in 2013 when I accidentally tripped and hit my head on the side of a table in my house.The gash was deep; I am told that the frontal bone just above my right eye was visible. I was rushed to a hospital, taken into surgery and given antibiotics and heavy doses of painkillers. In the end, I emerged with 18 stitches on my right eyebrow, a scar and a crazy story to tell. I was, however, otherwise unscathed.
Contrast my case with one from 80 years ago. In 1941, a 43-year-old policeman named Albert Alexander went to his garden to prune some rose bushes. During the process, he scratched the side of his mouth—insignificant compared to my case. Sadly, despite what may seem like an everyday and harmless occurrence today, Alexander soon had to be hospitalised. He had acquired an infection resulting in huge abscesses—collections of pus—in his eyes, lungs and face. The infection took a serious turn, and one of his eyes had to be removed.
Luckily for Alexander, researchers had identified a drug called ‘penicillin,’ which protected organisms such as mice from deadly bacteria. Alexander would become the first person to whom an antibiotic was administered. His condition immediately took a turn for the better, and he made a remarkable recovery. Sadly, the penicillin stocks ran out within some time, and he died.
Juxtaposing Alexander’s case with my own may make you realise the remarkable strides that medicine has made over the last century. However, it is sobering to learn that in future, millions of people may find themselves in situations like those faced by persons like Alexander, who lived before the advent of the ‘Antibiotic Era’.
Antibiotic-resistant bacteria
In 2008, a Swedish patient of Indian origin travelled to New Delhi and acquired a Urinary Tract Infection (UTI), caused by a strain of bacteria. The bacteria were later shown to possess a genetic factor, making them resistant to even the strongest antibiotics on the market. This factor was named ‘New Delhi metallo-beta-lactamase-1’ or ‘NDM-1′. This gene made the bacteria that possessed it resistant to all but one antibiotic available at the time[1]. One can reasonably imagine the existence of bacteria resistant to all known antibiotics.
It is easy to see from the above example why the issue of antibiotic resistance deserves our attention, care and action.The advent of the post-Antibiotic Era may be upon us, and, sadly, we as a species do not appear to be truly alive to the gravity of the situation. Indeed, our actions may even be contributing to the problem. Without effective antibiotics, the death toll among populations will rise exponentially, life expectancies will fall and we may not be able to perform routine surgical procedures like cesarean sections, bypass surgeries and transplants or even joint replacements and dialysis. In 2019, a study published in The Lancet attributed 1.27 million deaths to bacterial AMR (Anti-microbial resistance). By some estimates, up to 10 million people a year could lose their lives due to AMR by 2050.
Also read: US study on drug resistance says it led to 1.27 million deaths in 2019, more than HIV/AIDS
The process of natural selection
Imagine a population of bacteria, a hundred strong, for convenience. Of these, 95 bacteria are vulnerable to antibiotics, while the other five have certain mutations that allow them to ‘pump’ the antibiotics out of their bodies, rendering the drugs ineffective. Initially, only 5 per cent of the bacteria are drug resistant.
Let us say this population is exposed to small doses of an antibiotic. The drug successfully kills off 90 out of the 95 vulnerable bacteria. When the remaining organisms (five vulnerable and five resistant) reproduce, a single mother cell produces two daughter cells, leaving us with a population of 20 bacteria overall in the second generation, except, now, 10 bacteria are drug resistant and the other 10 are not. The colony went from a ’95-5′ distribution to a ’50-50′ one in a single generation. The’ weak’ bacteria keep dying as we keep using the same antibiotic. In contrast, the ‘fit’ bacteria are progressively selected through each generation until their drug-resistant genes are widespread in the entire population, making the antibiotic ineffective. This is a classic example of ‘natural selection,’ the process by which nature’s bad designs get progressively eaten up by her good designs, leading to the profound diversity and adaptations we see in the natural world today. Even in the bacterial realm, it is indeed the ‘survival of the fittest’, to use the phrase coined by the English economist Herbert Spencer in 1864.
The above example is arbitrary and simplified and is only intended to aid in explaining and understanding the phenomenon. In real life, the process of natural selection is vastly slower and is spread over multiple generations.
Several factors contribute to accelerating antibiotic resistance, some being natural while others are anthropogenic. One of the natural factors is the high rate of mutation among bacteria. When any cell divides, it first duplicates all its DNA content. Sometimes, during the reactions which replicate the DNA, random copying errors occur, which lead to slight changes in the characteristics of the offspring. A mutation can be understood as this small change produced due to a spontaneous copying error. The fact that bacteria mutate at high rates means that it is easier for them to develop mutations that help them evade antibiotics.
Another factor that promotes resistance is a phenomenon called ‘conjugation’. Scientists often explain this phenomenon through one or more variations of the following analogy. Imagine two friends, A and B, who go to a movie. ‘A’ is red-haired, while ‘B’ is brown-haired. After they leave the movie theatre, an observer is shocked to see that ‘B’ is now red-haired and ‘A’ is a brunette, with the two having nonchalantly exchanged DNA content between themselves inside. These changes are inheritable, with A’s offspring being all brown-haired and B’s offspring being all red-haired.
The above example may seem outlandish, but it does not occur in humans. A transfer of genetic information between two humans belonging to the same generation cannot occur. However, in the bacterial realm, this is a regular occurrence. Conjugation, thus, is the process by which bacteria’ swap’ exogenous DNA, leading to the exchange and proliferation of characteristics present in them. They can also take in genetic material from their environment (transformation) or have viruses transfer genetic material between them (transduction).
These phenomena make it easier for antibiotic resistance genes to travel between multiple bacteria, aiding their propagation.
Anthropogenic or ‘man-made’ factors that accelerate antibiotic resistance relate to the excessive use of antibiotics. These can be conveniently reduced to the following:
- Over-the-counter sale and use of antibiotics without medical prescription
- Reckless and irrational prescriptions from physicians
- Excessive antibiotic use in animal agriculture
According to the World Health Organization (WHO), over 50 per cent of antibiotic prescriptions worldwide are unnecessary. And 66 per cent of antibiotics available in the market are being used for self-medication and over-the-counter sale. The problem is further compounded by physicians prescribing medication unnecessarily, either for extra money or due to a lack of good quality medical education, particularly in low-income countries.
Another significant contributing factor is antibiotic use in animal agriculture. In the United States for instance, some studies estimate that up to 80 per cent of all antibiotics sold go to farm animals, not humans. This creates resistant bacteria that enter the meat we eat, facilitating their spread in humans. The bacteria may also move from the farms into the water supply, soil, or dust particles. Fruit farming also requires antibiotics to protect the growing fruits from bacterial diseases.
In addition, a study published in the ‘Nature’ journal shows that the pace of innovation and development in antibiotics has slowed over time. Perhaps pharmaceutical companies lack the incentives to produce more novel varieties of antibiotics. In 2017, researchers identified the cost of producing a new antibiotic at around $1,581 million. On the other hand, the estimated income generated from the sale of an antibiotic was less than $ 50 million per year. The short doses of antibiotics typically needed to reduce infection lower the volume of drugs that can be sold. Thus, reducing the money generated from their sale. In most countries, the prices of drugs like antibiotics are assessed and assigned by government agencies, not the manufacturers. This is done to ensure that medicines are affordable for people from all sections of society. Yet, unfortunately, this also contributes to lowering pharmaceutical companies’ revenue, magnifying the problem of antibiotic resistance.
Also read: Antibiotic resistance is the newest ‘silent killer.’ Move over Covid
Way forward
While these issues require public and scientific debate, a few simple measures are easily attainable. We, as consumers, should make it a point to check labels on animal products before buying them, making it a point to buy only antibiotic-free meat. This would help lower the financial incentive of pumping animals with drugs, discouraging the usage of antibiotics on factory farms and in meat processing units.
Awareness needs to be generated about the profound harm that self-medicating with antibiotics and their irrational use can cause. Laws should be enacted in all countries, making the sale of antibiotics without a licensed physician’s prescription illegal. Indeed, in India, such laws have already been passed. The Drugs and Cosmetics Act of 1940 and the Drugs and Cosmetics Rules, passed in 1945, list all antibiotics as prescription drugs, making their over-the-counter sale illegal. However, various studies have shown that the irrational sale of antibiotics is still rampant in the country. Patients can buy drugs without prescriptions and pharmacists dispense medications based on their hunches about the patient’s symptoms. Stricter monitoring and policing are thus necessary to implement these laws properly.
Government agencies are partly responsible for giving Big Pharma more incentive to invest money into antibiotic production. Committees can be formed to assess the resistance-price conundrum, setting and re-evaluating prices of antibiotics to benefit both companies and consumers best.
Technological solutions exist as well. The Covid-19 pandemic has shown us the value of proper monitoring, survey and data when solving public health crises. Strict monitoring of drug-resistant bacteria and data collection on the hot spots of resistant infections may prove crucial in the fight against the impending crisis.
Above all, we need to give the bacteria as little a chance as possible to infect us in the first place. Maintaining proper hygiene techniques like washing hands frequently, wearing masks in public places whenever possible, and ensuring access to clean water, food and toilets is needed to help prevent infection and contagion. Eating a well-balanced diet and following proper exercise regimens can help increase immunity. It will also be prudent to update vaccination records, ensuring no vaccinations are left due.
In conclusion, it is sufficiently clear that antibiotic resistance needs to be viewed as a global health emergency deserving our utmost care and attention. We are heading in the wrong direction, accelerating the production rate of resistant strains of bacteria and easing their proliferation, and we must change course immediately. Success or failure in solving this problem may define our future as a species.
Author is a student of class 11 at Step by Step School, Noida. Views are personal.