In the history of the United Nations, the General Assembly has only focused high-level meetings on health issues on three occasions: for HIV, Ebola, and chronic diseases like diabetes and obesity.
On Wednesday, September 21, 193 UN member states held one of these rare meetings on health: This time, to address the "nightmare" and "catastrophic threat" of antimicrobial resistance.
There are billions of bacteria that live in and around us, most of which help us survive and thrive. But some bacteria can make us sick, and antibiotics can kill off these harmful microbes. In addition to curing us when we're ill, these wonder drugs revolutionized medicine and vastly expanded the scale of food production.
Antibiotics have a major downside, though: The more we use them, the more quickly bacteria outsmart them, and the faster the drugs stop working.
Since Alexander Fleming discovered penicillin in 1928, he and many other scientists, public health officials, and doctors have been sounding alarm bells over antibiotic resistance. Yet we continue to abuse these drugs in medicine, inject them into our food supply, and use them liberally in everything from yoga mats to sanitation products.
Nearly a century after Fleming’s warnings, antibiotic-resistant bacteria have become a massive health problem worldwide, killing 700,000 people every year.
Over the past decade, entire countries, individual hospitals, and even food companies have made efforts to address the issue, which is increasing seen as not only a health problem but an economic and security threat, too. (Many attribute much of the recent attention to the work of the UK government, and in particular to the leadership of England’s chief medical officer, Dame Sally Davies.)
But even if some countries or major players take action, they won’t be able to fix the problem alone. To truly address superbugs, we need a global plan. (Remember: Microbes travel as easily as people can hop on planes.) We also need sectors — from health, agriculture, and security — to work together.
So far, we have done terrifyingly little to curb the resistance crisis at the global level, and the problem has been deemed "a classic 'tragedy of the commons'" on par with climate change.
That’s where this UN meeting comes in. Health experts are calling it a major turning point and a potential start for globally coordinated action. "Politically, I think people have woken up," said Marc Mendelson, an antibiotic resistance expert and professor of infectious diseases at the University of Cape Town.
"The last time the UN was poised to take major action on antimicrobial resistance was September 11, 2001," said Boston University’s Kevin Outterson, "[and] the release of the WHO Global Strategy in New York was lost after the terror attacks that day. It has taken 15 years to get back on the global agenda."
Here’s why the meeting was convened, what experts think should come out of it, and what's actually likely to change after today.
Why the UN is tackling this problem: Our antibiotic use is out of control
Though antibiotics still save millions of lives a year, more often than not, we use them incorrectly and unnecessarily.
The best estimates suggest that fully half of antibiotic prescriptions may actually be unnecessary. And specifically regarding emergency rooms and doctors' offices in the US, a recent study in JAMA estimated that 30 percent of antibiotics doled out were unnecessary, amounting to 47 million prescriptions every year. There’s also been a dramatic increase in the number of last-resort antibiotics being used in US hospitals.
Another study in JAMA found that doctors treat 71 percent of bronchitis cases, which are usually caused by viruses and untreatable with antibiotics. Doctors may know the drugs will be ineffective, yet they prescribe them anyway because patients demand them or they’re unsure of their diagnosis.
And that’s just medicine.
Most of our antibiotics are actually used in agriculture, in animals like chickens, cattle, pigs, and fish. In the US, for example, more than 70 percent of the antibiotics that are medically important for humans are sold for use in animals.
Farmers have typically used the drugs in three ways: to treat sick animals, to prevent infections, and to fatten up animals. The first use is uncontroversial, but public health experts have criticized the latter two uses. They argue that many livestock producers needlessly overuse antibiotics to prevent infections and promote growth — essentially relying on them as an alternative to hygiene and good nutrition. (These are considered "nontherapeutic" uses.)
The main concern with antibiotic use on farms is that it will lead to resistant bacteria that will make humans sick. Both the Food and Drug Administration and the Centers for Disease Control and Prevention have told Congress there's a link between the routine nontherapeutic use of antibiotics on farms and the superbug crisis in general.
"Poultry, cattle, and swine raised with antibiotics harbor significant populations of antibiotic-resistant bacteria, which are transmitted to humans through direct contact with the animals and through their meat, eggs, and milk," according to this Center for Disease Dynamics, Economics, and Policy (CDDEP) report on global antibiotic use.
Tracking the use of antibiotics and growth of superbugs on farms is a challenge everywhere, but it’s especially problematic in low- and middle-income countries, where there’s spotty lab capacity and disease surveillance systems in place. Worryingly, low- and middle-income countries are exactly where antibiotic use is expected to continue to rise, in particular, with the increasing demand for animal protein.
The rise of superbugs is threatening modern medicine
In recent years, antibiotic misuse has sped up the natural process of resistance, rendering some antibiotics useless and causing experts to warn that we are at the "dawn of a post-antibiotic era" that amounts to a health threat on par with terrorism.
In the US alone, antibiotic-resistant infections are associated with 23,000 deaths and 2 million illnesses every year. We’ve already seen a number of bacterial infections — gonorrhea, carbapenem-resistant enterobacteriaceae (CREs), strains of tuberculosis — that no longer respond to any of the drugs we have.
Overusing antibiotics also kills off the good bacteria in people’s bodies, potentially wreaking havoc on our microbiomes and weakening our immune systems. This means more people get sick, stay sick for longer, and die from resistant infections that we have no cure for — while the costs of treatment of antibiotic resistance go up.
A recent report commissioned by the UK government contains an alarming prediction: By 2050, antimicrobial-resistant infections will kill 10 million people across the world — more than the current toll from cancer.
It's not an overstatement to say that most of modern medicine hinges on the effectiveness of antibiotics and would unravel without effective drugs. Whenever you go to the hospital for an operation — a hip replacement, an ACL repair, heart surgery — almost without exception, doctors will give you a dose of antibiotics to prevent infection. Antibiotics also make the cesarean section, one of the single most life-saving procedures on the planet, possible.
Without antibiotics that work, common medical procedures like hip operations, C-sections, or chemotherapy will become more dangerous, and some medical interventions — organ transplants, chemotherapy — would be impossible to survive.
"It’s almost unimaginable how going back to a pre-antibiotic era would affect US health care," said Outterson.
Jirka Taylor, an analyst at the RAND Corporation, put it in these terms: "If you had a 5 percent chance of contracting an infection that had a 40 percent case fatality rate, would you still be interested in submitting to a relatively mundane procedure such as hip replacement, when your survival did not depend on it?"
What the best minds think we should do to solve the problem
A few key concepts are raised again and again and again when it comes to the problem of antibiotic resistance. "We may quibble over the details, but there is solid agreement on the science and basic policy directions," said Outterson.
You can organize these ideas under three broad categories: conservation, innovation, and access.
1) Conserving antibiotics by removing financial incentives for overuse, phasing them out of food production, and improving public awareness
We want to make sure the drugs we have continue to be effective, so we want to try to reduce the overuse and abuse of antibiotics. There are a number of interesting proposals to achieve this, as I’ve written before with Steven Hoffman.
a) The first is to remove the financial incentives that lead to irrational use. One way to do this is by "delinking" the pharmaceutical business model. The idea here is that traditional research and development models link the volume of patent-protected sales to the return on investment for companies. While drug companies still have their patent, they must sell as many drugs as they can — even if it's potentially dangerous for public health.
Through delinking, companies would instead be compensated for their antibiotic development on some other basis, such as grants or innovation prizes, instead of volume of sales.
b) The second key idea for conserving antibiotics is to phase antibiotics out of livestock when they’re used for prevention and growth promotion. Some countries are further along on this than others. Researchers and lawmakers who worry about the growing problem of drug resistance have been trying to get countries to go the way of Europe, where farmers now only use the drugs to treat sick animals.
The US is part of the way there. In 2014, the FDA set rules that asked livestock producers to phase out the use of antibiotics to boost animal growth (a practice that has been dwindling anyway). But the FDA ruling is voluntary, and didn't place any restrictions on using antibiotics for disease prevention.
c) Doctors also need to get better at curbing their overprescribing habits, and patients need to get better at not demanding the drugs when they’re not necessary. One way to do that is through better public education. There are huge gaps in knowledge when it comes to antibiotics.
In a World Health Organization survey on global antibiotic use across 12 countries, most people did not understand the basics of drug resistance, and how and when antibiotics should be used. That’s why health experts have called for mass public education campaigns.
2) Innovation of new antibiotics and better diagnostics
One of the scariest features of the antibiotic resistance crisis is that pharmaceutical companies aren't developing new drugs quickly enough: The drug pipeline is essentially dry.
Only a handful of new antibiotics have come on the market in the past decade, and health organizations such as the Infectious Diseases Society of America worry that progress on other drugs is "alarmingly elusive."
Drugmakers have been reluctant to invest in antibiotics because they don't offer great financial returns. Unlike treatments for chronic diseases, people only use antibiotics for short periods of time. And the calls to use them even more judiciously are not exactly an appealing business proposition for large pharmaceutical companies.
Though many of the best thinkers on antibiotics will argue that the conservation piece is as important as — or even more important than — the innovation piece, there’s no denying that we need more antibiotics in the pipeline. To encourage research and development, experts have been calling for a global innovation fund to fill in the gaps left by industry and support research on antibiotic resistance and its solutions.
Several countries, including the United States and China, have already started developing such funds, and in February 2016 the US government launched the BARDA Biopharmaceutical Accelerator to fund antibiotic research through partnerships with industry and nonprofit organizations.
Innovation on antibiotic resistance doesn’t just mean just developing new drugs. It also means investing in drug alternatives and better diagnostics to rapidly assess infections and avoid unnecessary prescribing. That’s why governments have been coming out with huge cash prizes for innovators who invent things like cheap, easy, and accurate point of care tests to diagnose bacterial infections.
3) Improved access to antibiotics, sanitation, and vaccines
The United States still leads the world in per capita antibiotics consumption. In 2010, there were 22 doses of antibiotics given to each person, compared with 11 in India and seven in China.
But while wealthy countries overall maintained or decreased their antibiotic consumption between 2000 to 2010, the BRICS countries had the biggest rise in antibiotic use: 68 percent in Brazil, 19 percent in Russia, 66 percent in India, 37 percent in China, and 219 percent in South Africa, according to CDDEP. "About three-quarters of the total increase in global consumption occurred in these nations; however, they accounted for only one-third of the world’s increase in population from 2000 to 2010," CDDEP reported.
In low- and middle-income countries, the major driver of infections — and the need for antibiotics — is still poor sanitation. Many people still live in areas that have been contaminated by human and animal waste, which is why ensuring clean water and sanitation for all are key to preventing the need for antibiotics.
Even though antibiotic overuse is a problem in many parts of the world, many people still don’t have access to these lifesaving drugs when they need them. This lack of access, or delayed access, to antibiotics actually kills more people globally than superbugs. For example, in a Lancet study, researchers estimated that improved access to antibiotics could mean preventing three-quarters of the deaths of children under 5 caused by pneumonia alone. (That’s about half a million deaths annually.) So improving access to affordable antibiotics would make a big dent in poorer countries' antibiotic resistance problems.
What's likely to come out of the UN meeting
On Wednesday, heads of state and leaders of delegations met to discuss the problem of antimicrobial resistance and together signed a UN declaration pledging to address "the biggest threat to modern medicine."
Don’t expect that to turn into global law. "The declaration will be as binding as any other UN General Assembly resolution," Outterson said, "but don't give it short shrift. This is historic global political engagement, and really good news."
Indeed, as global health researcher (and Vox contributor) Steven Hoffman explained, "The most impactful outcome of this meeting would be if it starts a longer-term process for countries to engage in a serious way on this issue."
Realistically, that means we’re probably not going to see any major new initiative or agency or structure that’s created at this meeting. Instead, member countries and UN agencies agreed to provide the UN Secretary General with an update on their fight against drug resistance in two years' time.
So at best, we might see targets with time horizons attached to them for things like reducing the use of antibiotics for growth promotion and disease prevention in agriculture, improved superbug surveillance, and pledges for dollars to support antibiotic innovation around the world.
But the biggest and more tangible immediate outcome of this meeting will be political. "It should sufficiently capture the attention of enough world leaders to realize this is one of the most fundamental issues of our time," Hoffman added. Considering the long history of the problem, and our failure to work together to tackle it, this attention alone is a pretty big deal.