Beating the Germ Insurgency

By Melinda Moore

Melinda Moore is a RAND public health physician with expertise in global health, military health, and emergency preparedness.

Antimicrobial drugs are designed to fight infectious diseases, but the germs are fighting back — and winning. Worse, the public has failed to grasp the global health threat posed by infectious diseases that are resistant to therapeutic drugs. Our complacency will be costly — and surely deadly.

Eight years ago, the World Health Organization declared that the threat of antimicrobial resistance was growing and that “our window of opportunity is closing.” It referred to the specter of a post-antibiotic era in which diseases resist virtually all available drug therapies. But this clarion call to arms has largely been ignored.

Taking on the microbial enemy will require an effective “counterinsurgency” effort. What is this enemy, what is the strategy, and how can we mobilize to win?

Antimicrobial resistance, or AMR, magnifies the threat from major infectious diseases for which there are therapeutic drugs but no vaccines: malaria, tuberculosis (TB), HIV, diarrheal diseases, and acute respiratory diseases. Compared with treating infections that respond well to ordinary treatments, treating drug-resistant infections is generally more difficult, more expensive, and not as successful.

Consider malaria, a disease that kills as many as two million people annually worldwide. Not long ago, a case of malaria could be treated with a single drug for about 8 cents. Now, because of resistance, treating malaria requires single drugs or drug combinations that cost $1, $7, or as much as $35 — a prohibitive expense in a poor country.

AP IMAGES/KEYSTONE/SALVATORE DI NOLFI  French Foreign Minister Philippe Douste-Blazy and Sweden’s Anders Nordstrom, acting director-general of the World Health Organization, speak in October 2006 about the work of UNITAID, which seeks to ensure access to AIDS, malaria, and tuberculosis drugs at an affordable price for everyone in developing countries. UNITAID was launched by Brazil, Chile, Norway, and France in 2006 and is supported by about 40 other countries.

TB is another prevalent and deadly example: About 5 percent of nine million new cases globally are resistant to at least two of the four standard drugs used. Treatment for drug-resistant TB costs about 200 times more than standard treatment and still results in lower cure rates.

Drug resistance is due in large part to antimicrobial drug misuse, such as poor prescribing practices: doctors prescribing too low of a dose, too short of a time, or just the wrong drug. Patients sometimes improperly self-medicate or demand inappropriate treatment. Drug quality is uneven. Institutional factors like poor hospital infection control and the inappropriate use of antibiotics in food animal production also play a role. Compounding the problem, market forces have led to lagging innovation in antimicrobial drugs.

All these factors demand a multifaceted strategy for the war on AMR — a comprehensive solution that will overcome global inertia and mobilize the tools we already have to beat this complex and wily enemy. And we need leaders — from the public and private sectors, health and non-health sectors — to mobilize the resources, support the research, lead the policy changes, and implement new ideas, including those outlined by the World Health Organization. We must create the market and social incentives to help drive such action.

In short, we must meet this major health threat or face the future of a dangerous post-antibiotic era. Unlike wars of the past, the war against AMR will never end. We must adapt and remain vigilant to help ensure a healthier world.