It’s been called a “threat to civilisation”. ‘And I don’t think that is an overstatement,’ says Professor Mathew Upton, head of research at the University of Plymouth school of biomedical sciences, UK. ‘It is certainly one of the larger threats to human health. The problem is that I’m not sure how news-worthy it is. And until people have personal experience of it, it just doesn’t seem very real to them’.
To what could he be referring? Nuclear war? Climate catastrophe? Asteroid impact? Rather, something that might seem much more innocuous: the growing resistance of germs to antibiotics. And if you think that’s minor, it was, after all, an infectious disease that killed half the population of the Byzantine Empire, or that wiped out most of the Native American population once Europeans arrived.
Just a century ago infections that we now dismiss – resulting from a small scratch, perhaps, or from having surgery – could prove fatal. Antibiotics were revolutionary life-savers. Go back just to the late 1940s and infectious diseases the likes of pneumonia and tuberculosis were leading causes of death in developed nations such as the US. Then almost miraculous penicillin and streptomycin changed all that.
The first comprehensive analysis of antimicrobial resistance predicts that, without a radical change in policy, a further 39 million people will die [of AMR] over the next 25 years
But now antibiotics’ efficacy is in free-fall, with microbial infection less likely to respond to treatment, leading to serious complications the likes of sepsis. You may have experienced being given one round of antibiotics to no avail, then another round of a second kind of antibiotic to try again – that is antibiotic resistance (more accurately known as ‘anti-microbial resistance’ or AMR) in action. Not that all anti-biotic-resistant ‘super bugs’ are inherently bad for you. You may have one living harmlessly in your gut. Harmless, that is, until it gets into your urinary tract…

Now the Global Research on Antimicrobial Resistance Project – the first comprehensive analysis of antimicrobial resistance over time – estimates that 36 million people have died as a result of AMR over the last 25 years, and predicts that, without a radical change in policy, a further 39 million people will die over the next 25 years. Anyone who needs drugs to suppress their immune system – so treatment for the likes of cancer or after organ transplant, for example – is especially at risk. No wonder then that the UN General Assembly met in autumn last year to discuss what can be done.
How Antibiotics Are Losing the Battle
To be clear, all antibiotics become less effective over time. One common misconception is that it’s people who become resistant to the positive effect of antibiotics. What’s actually happening is that bacteria – programmed to reproduce and pass on their genes like all living things – adapt to circumvent the effects of antibiotics. Different species of bacteria can even share this adaptation between them. Then humans and animals pass the adapted bacteria around too (even to those who have never taken antibiotics). So it’s an arms race, with the development of new antibiotics constantly trying to outpace bacteria naturally building up a resistance to them. Indeed, typically within a decade of introducing a new antibiotic resistance becomes a clinical issue.
While approaches vary from culture to culture, it’s also often been supercharged by doctors’ over-readiness to prescribe them too, because they feel under pressure from patients to ‘do something’ to tackle a problem that will likely solve itself given just time and rest
And therein lies the problem that the UN has called “the biggest threat to modern medicine”. That resistance has been super-charged by patients’ mis-use – buying them privately without a doctor prescribing them, failing to complete the course (even if they feel better), saving some for later and sharing them with friends or family. While approaches vary from culture to culture, it’s also often been supercharged by doctors’ over-readiness to prescribe them too, because they feel under pressure from patients to ‘do something’ to tackle a problem that will likely solve itself given just time and rest.

As one Bond University, Queensland, study put it, “[most] people knew that using too many or unnecessary antibiotics caused antibiotic resistance. The problem was they did not think they used too many or that their antibiotic use was unnecessary. They typically thought other people were the issue…”
You can’t treat that sore throat or nasty cold with antibiotics, nor athlete’s foot. You might as well use a plaster. No wonder we’re seeing more strains of bacterial diseases the likes of MRSA, salmonella and E.Coli that have developed resistance.
Indeed, while good medical practice should regard their use as a last resort – precisely because the more they’re used, the less useful they become – many patients don’t even understand that antibiotics are solely for the treatment of bacterial infections. They’re no good for viruses, for example. You can’t treat that sore throat or nasty cold with antibiotics, nor thrush or athlete’s foot. You might as well use a plaster. No wonder we’re seeing more strains of bacterial diseases the likes of MRSA, salmonella and E.Coli that have developed resistance.
‘Antibiotics get used when they shouldn’t be, because they’re inappropriate for a condition that doesn’t need them,’ explains Upton. ‘There’s just the [misguided] perception with a lot of conditions that antibiotics is the way they’ve always been managed. And it’s easier for a doctor to prescribe antibiotics for, say, a UTI when no investigation has been carried out but also when those doctors have not been supported with the tests that allow them to do that rapid and cheaply.’
That over-use extends to the much less well-regulated world of farming as well, and industrial-scale factory farming in particular. Since infectious disease is rife, and spreads virulently, among such huge numbers of animals kept in such close proximity – and often not under the most hygienic conditions at that – antibiotics are used liberally to tamp it down. While it’s banned in some parts of the world, antibiotics are also used to promote animal growth.
A Broken Business Model
It’s also a matter of how the pharmaceutical industry works. Researching and developing antibiotics takes hugely complex scientific work over many years and costing maybe billions of dollars, and it’s a gamble that anything will come of these efforts. Even if it does, since they should be used very sparingly and, when they are, also need to be accessibly priced, the opportunity for their developers to recover their costs, let alone make a profit, is severely curtailed. So much so, in fact, that most big pharmaceutical companies long since pulled out of antibiotic R&D, leaving most of the work now to small biotech start-ups and not-for-profit organisations. No new classes of antibiotics have been discovered since the 1980s.

‘The route to developing new antibiotics isn’t broken but, when antibiotics tend to be sold for pennies, clearly the economic aspect is,’ says Upton.
There are, he adds, many proposals about how to address this situation: governments giving successful developers a lump sum payment, for example; implementing a Netflix-style subscription payment model, with governments paying pharmaceutical companies up-front for access to their drugs; or allowing pharmaceutical companies to off-set their antibiotic development costs by being permitted to extend patent exclusivity on some other, more lucrative drug that they’ve developed. Some have even argued for legal limits to the use of antibiotics. But take up of these ideas hasn’t been enthusiastic. At best, more countries – the UAE included – are now operating national surveillance systems to monitor anti-biotic effectiveness and any growing resistance.
What’s really needed, many experts claim, is a so-called ‘one health’ response – one that’s global; one that incorporates animal farming and, for that matter, sewage treatment and food production too; one that encourages us all to be aware that we’re part of the solution. Sometimes called ‘the silent pandemic’ – because it’s happening, and on a huge scale, but quietly in the background – we need to be talking about AMR more.
As the World Health Organisation has said, if we don’t act, the world will continue to head towards a ‘post-antibiotic era in which common infections will once again kill, [and] sophisticated interventions, like organ transplantation, joint replacements, cancer chemotherapy, and care of pre-term infants, will become more difficult or even too dangerous to undertake’.
We are, reckons Upton, at least starting to take the right steps. ‘There are a lot of initiatives in play and changes in regulations, so overall I’m still positive,’ he says. ‘That said, I still get worried if one of my kids get ill and need antibiotics. I still wonder ‘will they work?’.