By Christopher Metzger

What is antimicrobial resistance?

Antimicrobial resistance (AMR) refers to the ability of microbes to grow in the presence of substances specifically designed to kill them, specifically antibiotics. Superbug is a non-scientific term used by the media to refer to a pathogenic bacterium that has developed an immunity to antibiotics. The annual economic costs of AMR and superbugs—measured in lost productivity—could be as large as that of the 2008 global financial crisis. Without a global containment effort, the Sustainable Development Goals (SDGs) will be out of reach. In particular, goals 1 and 3—ending poverty, and achieving good health and well-being—will be unreachable by 2030. If containment efforts fail by 2050, more people will be dying from resistant bacteria than from cancer, as shown in Figure 1. The deaths and medical costs that would result from widespread drug-resistant bacteria could cost developing countries five percent of their gross domestic product (GDP) by 2050, yet the threat of superbugs is only just beginning to receive the international media attention that it deserves.

Public knowledge of AMR and superbugs may not be as widespread as awareness of the Ebola and Zika outbreaks, but the international community must recognize that everyone—not just developing countries—is at risk. The Center for Disease Control (CDC) estimates that antibiotic-resistant bacteria are responsible for at least two million illnesses and 23,000 deaths annually in the United States alone. Close to 50,000 of the 700,000 yearly deaths from drug-resistant strains of tuberculosis, sepsis, diarrhea and other illnesses occur in Europe and the United States. Developed and developing countries must work together in order to contain the outbreak of AMR.

This article explores the future economic costs of a massive outbreak of AMR in developing countries and makes recommendations on how different stakeholders can work together to contain the problem in the present.

What contributes to the evolution of drug-resistant diseases?

Misinformation, which leads to the global overuse and misuse of antibiotics, has significantly contributed to the development of AMR. In many cases, citizens of developed and developing countries are unaware of the excessive use and prescription of antibiotics. In a 2015 survey, the World Health Organization (WHO) found that 76 percent of respondents across 12 countries incorrectly believed that antibiotic resistance occurs when their bodies becomes resistant to antibiotics. It is the bacteria, not humans, that becomes antibiotic resistant. Even more troubling is that 44 percent of respondents thought that antibiotic resistance is only a problem for people who take antibiotics regularly, disregarding the antibiotic content of meat from food-producing animals. In the United States, 70 percent of all antibiotics sold are given to food-producing animals, often to promote growth and to compensate for the effects of unsanitary and overcrowded conditions.

In addition to misinformation, low and middle-income countries suffer from a growing unregulated black market for counterfeit medications. The WHO estimates that 25 percent of all drugs sold in developing countries are counterfeits. Not only are drug counterfeiters taking advantage of the high demand for medication, but fake or poor quality medication is also contributing to the evolution of new drug-resistant strains of common illnesses like malaria. Resistance to artemisinin, the main component of all malaria pills, has now been confirmed in Cambodia, Laos, Myanmar, Thailand and Vietnam, and the estimated productivity losses from related morbidity and mortality is $385 million a year.

Global repercussions

The world economy is expected to grow at an average of three percent every year until 2050 without taking into account the massive economic damage from the global outbreak of AMR.

In a 2016 report, the World Bank ran two simulations: one optimistic “low-AMR” scenario modeled as shocks to the labor supply and to livestock productivity, and one “high-AMR” where the shocks are more severe. They estimate that world GDP will decrease by 1.1 percent in the “low-AMR” simulation and 3.8 percent in the “high-AMR” case, as seen in Figure 2. A decrease of 3.8 percent may not sound like much, but it would result in an additional 28.3 million people becoming extremely poor by 2050, causing the world to be a very different place.

In the report, the impact of AMR on lower middle-income countries and low-income countries was much more significant because they lack of resources to fund research and the development of new antibiotics, demonstrated in Figure 2. The costs of containing superbugs once they become widespread will be much greater than attempting to contain the problem right now when many of the drug-resistant diseases are relatively rare.

The consequences of AMR are extensive, threaten the achievement of the SDGs and severely weaken the economies of developing countries. The direct consequences include longer illnesses, increased mortality, prolonged stays in hospitals, loss of protection for patients undergoing operations and other medical procedures, and increased costs. The indirect impact is a drain on the global economy with economic losses due to reduced productivity caused by sickness (of both human beings and animals) and higher costs of treatment.

What is being done to combat the problem of antimicrobial resistance and superbugs?

In 2014, President Obama responded to the threat of AMR by issuing an executive order to create a task force and presidential advisory council on combating antibiotic-resistant bacteria. In September 2016, the U.S. Department of Health and Human Services launched a $20 million competition as part of the National Action Plan for Combating Antibiotic-Resistant Bacteria to incentivize the development of new diagnostic tests that healthcare providers can use to quickly identify antibiotic-resistant bacteria, and distinguish between viral and bacterial infections as described in Figure 3. While this competition could prove to be successful, it is a long-term solution to the problem and one that needs to be coupled with other short-term measures.

	National Action Plan for Combating Antibiotic-Resistant Bacteria
1.	Slow the emergence of resistant bacteria and prevent the spread of resistant infections
2.	Strengthen national one-health surveillance efforts to combat resistance
3.	Advance development and use of rapid and innovative diagnostic tests for identification and characterization of resistant bacteria
4.	Accelerate basic and applied research and development for new antibiotics, other therapeutics, and vaccines
5.	Improve international collaboration and capacities for antibiotic-resistance prevention, surveillance, control, and antibiotic research and development

Figure 3 is an original creation by the author, Christopher Metzger, using information from the U.S. Department of Health and Human Services’ “National Action Plan for Combating Antibiotic-Resistant Bacteria” report.

On September 21, 2016, the United Nations (UN), held a high-level meeting to reaffirm their commitment to the WHO’s Global Action Plan on Antimicrobial Resistance which calls for innovative research and development, affordable and accessible antimicrobial medicines and vaccines, and increased international cooperation to control and prevent AMR. The UN and the rest of the international community are finally beginning to recognize the critical importance of containing the spread of superbugs before their impact multiplies, but they need to act quickly.

Recommendations

It is imperative that governments, the WHO, the Food and Agriculture Organization of the United Nations (FAO), the World Organization for Animal Health (OIE), NGOs, private pharmaceutical companies, and individual citizens work together to combat AMR and prevent the impending economic repercussions that could cripple the developing world.

Governments across the globe and especially in developing countries should recognize that the economic costs of AMR containment today are significantly less than those once the number of drug-resistant diseases vastly increases, and larger portions of human and animal populations are infected.

The following recommendations are for the various stakeholders that need to be engaged in AMR containment:

Countries at risk:

• Introduce regulations now to prevent the misuse and overuse of antibiotics
• Require companies to list the amount of antibiotics they give their food-producing animals and encourage them to provide better living environments for animals
• Increase penalties for smuggling counterfeit drugs into their countries to shrink the growing black markets in Africa and Asia
• Fund research on AMR and the development of new antibiotics

The WHO, FAO, OIE:

• Continue to raise awareness of drug-resistant diseases and how the average citizen often unintentionally misuses and overuses antibiotics
• Launch campaigns to distribute this information online or through mobile technology such as applications and text messages to reach people in remote places
• Provide long-term investments in developing new medicines, diagnostic tools, vaccines and other inventions
• Track the spread of AMR and the evolution of new resistant strains of common diseases

NGOs:

• Conduct research in order to determine the appropriate incentives to have pharmaceutical companies more involved in this discussion and demonstrate economic implications of AMR
• Research the best ways to reduce the amount of antibiotics given to food-producing animals without raising the price of food to unsustainable levels

Pharmaceutical Companies:

• Develop new antibiotics to combat AMR

Individual citizens:

• Only take antibiotics that they are prescribed
• Choose meat without antibiotics if possible