This piece is by Ramanan Laxminarayan, who has worked with the World Health Organization (WHO) and the World Bank on disease control and policy evaluation and is currently the director of the Center for Disease Dynamics, Economics & Policy.
The year 2015 marks the target date for completion of the eight United Nations Millennium Development Goals (MDGs), a set of objectives laid out by world leaders in 2000 with the aim of, among other things, improving global health and preventing the spread of infectious diseases. Great strides have been made in combatting “HIV/AIDS, malaria and other diseases” (MDG 6). According to the UN’s 2013 progress report on the MDGs, several of the objectives laid out for fighting infectious diseases have been reached. The MDG target of halting and beginning to reverse the spread of HIV, for instance, has been met, and access to HIV treatment has been dramatically expanded. The death rate from tuberculosis decreased 41 percent in 20 years, and global malaria deaths were reduced by 26 percent between 2000 and 2010. We have also taken significant steps toward achieving the targets laid out in MDG 4 by reducing child deaths, which are commonly caused by diseases like pneumonia and malaria. Indeed, the under-five mortality rate decreased by 47 percent between 1990 and 2013.
Our progress in fighting infectious diseases and saving lives, however, could grind to a halt – or even be reversed – if we do not address the increasingly pressing issue of antimicrobial resistance (AMR). In its first global report on AMR, released in early May, the World Health Organization (WHO) warned that high rates of resistance have been observed around the world in bacteria that cause common illnesses, such as urinary tract infections, pneumonia, gonorrhea, and staph infections. As WHO Assistant Director-General for Health Security Keiji Fukuda points out in the report’s foreword, “a post-antibiotic era – in which common infections and minor injuries can kill – far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century.”
- While the MDG progress reports have shown decreasing HIV infection rates and increased access to treatment, the World Health Organization has reported higher transmission rates of antiretroviral-resistant strains of HIV. It is estimated that between 10 and 17 percent of patients without prior antiretroviral treatment in Australia, Europe, Japan, and the United States are infected with an HIV strain that is resistant to at least one antiretroviral drug.
- The re-emergence of malaria in countries like Venezuela, which were considered free of the disease for decades, shows that proper surveillance and prevention are lacking in many parts of the world. Adding to the problem are artemisinin-resistant strains of malaria, which have been identified in five countries in Southeast Asia and pose a risk to other countries in the region.
- Multidrug-resistant tuberculosis (MDR-TB) is also becoming ever more common. There were approximately 450,000 new cases of MDR-TB in the world in 2012, more than half of which occurred in China, India, and Russia. In many countries, more severe strains of extensively drug-resistant TB (XDR-TB) are increasingly prevalent.
These numbers paint a worrying picture: If left unchecked, antimicrobial resistance could mean the undoing of all the progress made under the MDGs. The Sustainable Development Goals (SDGs), which are part of the UN’s post-2015 development agenda, must emphasize antimicrobial resistance as a threat to global health that must be overcome.
Improving surveillance of antimicrobial consumption and resistance is one of the most important steps in this process. The WHO report threw into sharp relief the inconsistent, underdeveloped surveillance techniques that are used in much of the world. In order to better fight AMR, we must reach a global consensus on the standards used to track resistance indicators. This will require the establishment of national databases to track antibiotic sales, consumption, and bacterial resistance profiles. It will also require collaboration between nations. Efforts such as the European Antimicrobial Resistance Surveillance Network (EARS-Net) and the Center for Disease Dynamics, Economics & Policy’s Global Antibiotic Resistance Partnership, which seeks to establish actionable policy proposals on antibiotic resistance in low- and middle-income countries, are already underway – but more such initiatives will be necessary.
Doctors, patients, and pharmacists must also be educated on proper prescribing practices and use of antimicrobials. In many countries, antibiotics are sold in pharmacies without a prescription, and even in countries like the United States, where over-the-counter laws are strict, it is estimated that half of antibiotic prescriptions are unnecessary. The indiscriminate prescribing and consumption of these drugs are contributing to the rising rates of resistant bacteria in both community and health-care settings.
The situation is further complicated by the dwindling supply of effective drugs. Overcoming this obstacle will require a multipronged approach that pushes for investment into research and development efforts, as well as the removal of bureaucratic barriers that often stand in the way of the approval of new pharmaceuticals.
Ensuring that there is a concerted international effort to address these problems will undoubtedly present a challenge for the global health community. With the MDGs in their final stages, governments around the world must come together to set new goals that ensure the gains we have made since 2000 are not lost to the threat of drug-resistant bacteria.