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Hope or despair towards antimicrobial resistance?

The 5th World Antibiotic Awareness Week (Nov 13 - 19) is an annual campaign by the World Health Organization (WHO) to increase public awareness of antimicrobial resistance (AMR) as well as antibiotics as a precious and finite resource.

The 5th World Antibiotic Awareness Week (Nov 13 - 19) is an annual campaign by the World Health Organization (WHO) to increase public awareness of antimicrobial resistance (AMR) as well as antibiotics as a precious and finite resource. 

Antibiotics are commonly accepted as “miracle drugs” that convey upon humanity the capability to cure bacterial infections. Without them, many modern medical interventions such as cardiac surgery or cancer chemotherapy will extract such a high toll in terms of death and disability that they will be attempted only for the most exigent of cases.

AMR, according to the WHO, is the ability of a microorganism (most commonly bacteria, but also viruses, fungi and parasites) to stop antimicrobial agents such as antibiotics from working against it, thus rendering the treatment ineffective.

There is the sense, shared by many countries worldwide, that a tipping point has been reached.

Over the past two decades, the rate of proliferation of antibiotic-resistant bacteria has risen globally, even as fewer new antibiotics reach the market. Frequently, the news media and some health professionals have spoken alarmingly of an “antibiotic apocalypse” or “post-antibiotic era”.

These events led to the development of a Global Action Plan against AMR by WHO in 2015, and subsequently world leaders made an unprecedented commitment to address this challenge at the United Nations high-level meeting on AMR in September last year.

Singapore has also just launched its own National Strategic Action Plan on AMR this month. In line with the Global Action Plan, the strategic interventions are cross-sectoral and in the areas of education, surveillance, research, prevention of infection, and optimisation of antibiotic use.

From a global perspective, however, two key questions remain: can the “doomsday scenario” of AMR, where we are once again unable to treat bacterial infections with antibiotics, be averted? And if so, how would this best be accomplished?

CAN SINGAPORE SHOW THE WAY?

For the first question, the fear of AMR is the medical counterpart of the “Malthusian catastrophe” – the well-known prediction that when population growth is unchecked and outpaces food production, society will experience widespread famine and population die-off before returning to the subsistence level.

Historically, the fear of a Malthusian collapse triggered attempts to control population growth in many countries in the second half of the 20th century. Ultimately the Green Revolution, through the development and transfer of technological advances in agriculture between countries, helped food production keep pace with population growth.

It may be tempting to attribute the success of the Green Revolution to genetically engineered crops. But if recent 20th century history is anything to go by, it is that whether agriculture or healthcare succeeds has less to do with novel technology per se than the different social factors that make technology work. This leads us to the second question. Just as crucial is the collaboration between various parties and attention to deep scientific research.

Take the example of the WHO itself, formed in 1948. It was apolitical and scientific in its approach to disease and health. The organisation – along with others such as the Food and Agriculture Organization – are part of what historian Akira Iriye called a ‘global community’ that grew after the Second World War. Nevertheless, the early history of WHO was marked by overconfidence in scientific advances, which led to technological failures.

The most infamous example was the widespread use of DDT to eradicate malaria worldwide.

This ill-informed application of chemical technology not only damaged the environment and ecosystem, but also enhanced microbial and mosquito resistance to DDT.

The anti-malaria campaign also suffered from Cold War politicking between the superpowers. Learning its lesson, WHO subsequently paid greater attention to scientific research in more modest eradication campaigns against smallpox, polio and leprosy.

Instead of relying on ‘magic bullets’ alone, WHO also strove to support comprehensive and sustainable health systems in individual countries, that had adequate medical staff, facilities and technical expertise .

The 20th century was one of great confidence in science, development and technology.

History suggests that this confidence ought to be tempered by greater collaboration across borders. We can similarly be more hopeful about AMR and the future of antibiotics if we look beyond technology to pursue greater collaboration among scientists as well as between them and international organisations, national governments and local communities.

What about Singapore? Our country is not spared from the problems caused by AMR.

Our hospitals have been afflicted by various outbreaks of “superbugs” since the 1970s, most of which have become endemic.

In the past, the issues with antibiotic-resistant bacteria have mostly been ameliorated by the emergence of new antibiotics in the market. Local healthcare staff have also become increasingly competent in dealing with each such bacteria over time.

Increasingly, however, infections occurring in Singapore’s hospitals can only be treated with a handful of costly antibiotics – or just one single antibiotic polymyxin B that was developed in the late 1950s but hardly prescribed between the 1970s and early 2000s because of its kidney toxicity.

Even in the community, more infections are caused by a greater variety of antibiotic-resistant bacteria.

Learning from 20th century history, we can aim to increase the knowledge of school children about AMR – including antibiotic use in animal husbandry and the environment, nudge patients not to request antibiotics from their doctors and share data publicly regarding certain hospital, community and agricultural rates of AMR.

We can also heighten investment in biomedical and social science research in AMR and infection prevention, and extend such research and operational expertise to the region while rapidly adopting and adapting relevant technological innovations or new antimicrobial compounds, to name but a few of the more relevant interventions.

We are one of few countries with the potential to slow or even reverse some of these trends relatively rapidly, despite being open to the world and dependent on food production from overseas.

Ours is a small city-state with an efficient civil service and a highly regarded healthcare system. We have also invested heavily in biomedical research and technology, all of which should stand us in good stead for the future.

 

ABOUT THE AUTHORS:

Dr Loh Kah Seng, a historian, is researching the history of tuberculosis in Singapore. Associate Professor Hsu Li Yang leads the Antimicrobial Resistance Programme at the NUS Saw Swee Hock School of Public Health.

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