This article is part of the Future Agenda, a series from Future Tense in which experts suggest specific, forward-looking actions the new Biden administration should implement.
As Joe Biden enters the White House this month, his most urgent priority is getting a grip on COVID-19, starting with a campaign built around 100 (million) shots in 100 days. But a national security priority for the next few years will be preventing the next pandemic, and a vital part of that should be leading a global effort to protect one of our most important infection-fighting tools: antibiotics.
There are a number of potential sources for future pandemics. Perhaps a bioterror research effort that somehow slips past all four of the staff members worldwide supporting implementation of the Biological Weapons Convention. Or another virus—perhaps a new strain of Nipah or a coronavirus—might make its way from animals to humans. But a considerable and growing threat comes from a mutated strain of bacteria invulnerable to antibiotics like penicillin or tetracycline.
There’s a risk of bacteria developing resistance every time we use antibiotics. If the drug isn’t strong enough to kill all of the microbes, the ones that survive are those already most resistant. Bacteria reproduce very fast, so they can rapidly evolve into forms that are better able to survive being bathed in ever-stronger concentrations of the antibiotic: in one test, increasing resistance a thousand-fold in just 11 days.
It is little surprise that resistance has been a growing problem ever since Alexander Fleming first experimented with penicillin back in the 1930s. For example, 1972 saw a typhoid fever outbreak in Mexico that was stubbornly resistant to chloramphenicol, and when doctors switched to streptomycin, sulfonamide, and tetracycline, none of them worked, either. Thankfully, despite spreading to the U.S., the outbreak burned out within a year.
But the resistance problem has exploded in the past two decades. The Centers for Disease Control and Prevention says there are 16 different fungi and bacteria that have developed antibiotic resistance and present an urgent or serious threat to human health as a result. In the U.S. alone there are more than 2.8 million antibiotic-resistant infections each year, and more than 35,000 people die as a result. Methicillin-resistant Staphylococcus aureus, or MRSA, is one example: It is particularly common in hospitals, where it can infect the blood stream or surgical wound sites as well as cause pneumonia. It kills more than 10,000 people each year in the U.S. alone. Worldwide, 700,000 people die of resistant infections every year, and a U.K. government-sponsored review of the issue recently estimated that number could climb to 10 million a year by 2050. A whole range of operations and treatments might become simply too risky to try in a post-antibiotic world including chemotherapy, joint replacements, and organ transplants.
And yet we are making the resistance problem worse. One factor behind bacterial spread in both hospitals and the wider world is inadequate sanitation: cleaning surfaces, equipment, and hands; hundreds of millions lack access to clean water and a safe toilet. Another is inappropriate prescription and control of antibiotics. In the U.S., for example, only about 10 percent of bronchitis cases involve a bacterium, but doctors prescribe antibiotics as treatment to 70 percent of patients. And even without a prescription, it is easy to buy antibiotics online. Between 2000 and 2015, human antibiotic consumption worldwide increased 65 percent, driven by increases in developing countries.
Then there is profligate use on farms: Animals make up about four-fifths of all antibiotics consumed each year in America, mostly to promote more rapid growth, and most of the volume is made up of drugs important for treating disease in humans. That helps to explain why 50 percent of chicken sampled from U.S. supermarkets contains campylobacter bacteria that is resistant to the antibiotic tetracyclin and half of the salmonella found in retail chicken is multidrug-resistant. Worldwide, about 70–80 percent of total antibiotic production is consumed by livestock.
COVID -19 is a particularly vivid reminder of something we’ve long understood: Microbes can cross borders quickly and easily. Resistant bacteria are a global threat elevated by global misuse. That’s why the Biden administration should lead the world toward an international agreement on tackling antimicrobial resistance.
A first step would be accurate data: on antibiotic use but also on resistance and the illness and deaths that it causes (chronically underreported in the U.S.). Beyond that, the agreement should limit the use of the most medically important antibiotics in farming and set simple, monitorable global rules around antibiotic prescribing practices. That won’t fix the problem of resistance, but it should give us more time to develop new antimicrobials—and the U.S. and other rich countries should pitch in funding to bulk up a drug pipeline that is woefully inadequate. Finally, the agreement should set up a system for regular reviews of progress and the opportunity to tighten controls if these initial moves are not enough to reverse the trend toward mounting multidrug resistance.
Despite the rising death toll from antibiotic resistance, we have been lucky so far that a highly contagious lethal bacteria hasn’t become impervious to the drugs. But the pandemic has amply demonstrated the kind of costs we could face if it did. It is past time for the world to act.