It is now a year since the UK Chief Medical Officer, Dame Sally Davies, increased national awareness of the serious threat posed by antibiotic resistance. Speaking to a House of Commons select committee she said that the issue was so serious it should be added to the Government’s national risk register of civil emergencies, alongside terrorism. She described an apocalyptic scenario where failing to take effective action would result in an end to cancer chemotherapy and organ transplantation, while routine operations, such as hip replacements or Caesarians, would cause patients to die of untreatable infections.
Worldwide about half of all antibiotics are used on farms but this is only part of the problem. We are also taking too many antibiotics, with 9 out of every 10 doctors prescriptions for antibiotics considered unnecessary. The problem is growing because antibiotic resistance increases much faster than it is possible to develop new antibiotics. A few new antibiotics have been introduced during the last decade, but they have all been derived from existing antibiotic classes, and infectious bacteria that are resistant to one antibiotic in a class are generally resistant to them all. In reality there has been no new major class of antibiotics since the ‘carbapenems‘ were developed in the mid-1980s, and in the last few years resistance to these has started to occur, causing much of the recent concern.
We are all familiar with the term ‘peak oil’ and often hear the debate about when it might occur, but peak antibiotics occurred in about 1960. The dramatic success of penicillin led to mass exploration of the naturally occurring microbes from which new antibiotics could be developed. The market was flooded with antibiotics from the easiest sources, but with the benefit of hindsight we can see that a false sense of plenty was created. Over the last five decades it has became progressively more difficult and expensive to develop new types of antibiotics. Today we are scraping the barrel, and while we must hope that major new classes of antibiotics will yet be developed, it is almost certain that these will be relatively few in number and that those we now have are the best we will ever have.
The good news is that resistance does decline if we cut back significantly on use. In recent years hospital doctors have made concerted efforts to reduce the use of certain critically important antibiotics and resistance levels have fallen as a result. Yet the use of the very same classes of antibiotics in farming has continued to increase. Studies show that following the EU-wide ban on the use of antibiotics for growth promotion in the late 1990s, resistance fell from very high to very low levels for the antibiotics monitored. So following this example we now need to find ways to reduce the farm-use of all antibiotics, especially those given to animals as a cheap form of insurance.
But what is the best way to do this? After years of lobbying by campaigners, an attempt will now be made in the US to end the use of antibiotics for growth promotion, through a voluntary agreement between the Food and Drug Administration and industry. If this is effective, it is likely to spread to other countries that still allow this practice. Yet since the guidelines are voluntary, and farmers will still be able to use the same antibiotics routinely to prevent disease, no one is expecting to see a very big fall in their overall use.
In order to address this issue, two Canadian economists, Aidan Hollis and Ziana Ahmed have recently suggested imposing a tax on antibiotics as the best way to limit their use. They recommend the tax should be highest on the antibiotics we are most concerned about, and lowest on those we are least concerned about. Farmers wouldn’t be banned from using any antibiotics, but the pricing structure would strongly discourage inappropriate use of those that are of greatest importance in human medicine.
Morally, there is a strong case for taxation. The true cost of antibiotic resistance is approximately £10 billion a year in the UK and $55 billion a year in the US. Roughly half the costs are related to additional time in hospital and higher treatment costs, in the case of the US, for the 2 million Americans infected by a resistant bug every year. The other half relates to additional care costs and loss of productivity due to time off work. And yet even these amounts are gross underestimates of the true cost of resistance because we are heading towards the eventual breakdown of healthcare systems as we currently know them. The full-cost of widespread resistance to antibiotics and the impact this would have on human health is impossible to estimate accurately, but we know this would be devastating and immense.
Money raised through taxes could also be used to fund increased research into new antibiotics. Critics might argue that a tax on farm antibiotics would ultimately be passed onto consumers in the form of higher prices. That could well happen, but ultimately society has to decide whether or not it is willing to pay a bit more for some foods, to help prolong the ability of antibiotics to save lives for the benefit of society as a whole and future generations.
But would taxes on their own make a big enough difference? We can’t be sure as they have never been tried, but to use antibiotics wisely requires a high level of professional expertise and effective regulation. If we relied on taxes alone – as is being suggested – farmers might cut costs by using lower doses of antibiotics and that would make the situation even worse, because it creates the conditions where resistance develops most rapidly. It could also lead to increased use of the antibiotics currently not seen as critically important. Yet as the resistance problem continues to worsen it becomes increasingly clear that we can no longer afford to use any antibiotics irresponsibly – they will all be needed in the future.
Photograph by Jenni Konrad
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