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2 april 2019

"With the rise in antibiotic resistance potentially rendering vital treatments ineffective, are we facing a postantibiotic era that resembles [the] preantibiotic past?" (14) That is the thesis question of a provocative book by William Hall, Anthony McDonnell, and Jim O'Neill called Superbugs. Though none of them wrote the sentence – it comes from the first chapter, which was written by Jeremy D. Knox, credited only in a footnote. For a group effort, Superbugs is remarkably coherent.

Superbugs gives a solid introduction to the biology and epidemiology of bacteria, and it's good on the history of the drugs and the microbes that resist them. But the authors are mainly concerned with economics and public-health policy.

Systematically and forcefully, without shock-horror rhetoric, Hall et al. explain that humanity as a whole is threatened by the rise of antibiotic-resistant bacteria. Well, probably not threatened with extinction. As noted above, we got along pretty well without antibiotics for a few million years. But life then was nasty, brutish, and short. Life expectancies have increased all over the world in the past couple of centuries. Better sanitation, better public-health practices, and better surgery have been big factors, but antibiotics are central to gains since the 1940s. Among other things, antibiotics have made modern surgery possible, by suppressing possible postoperative infections. Transplants would be unthinkable without effective antibiotics.

And antibiotics get less effective the more they are used. Not the more they're used on a given patient, mind you. Hall et al. note a popular misconception that people's bodies become resistant to antibiotics. That's not the case; if an antibiotic works, it will work no matter how many times you take it. If it doesn't, it won't even work once. And antibiotics are working less and less often all the time.

Alexander Fleming, discoverer of penicillin, realized at the start that overuse of his drug could undermine its effectiveness. The more a drug circulates in the environment – including among livestock and wastewater systems – the more bacteria evolve resistance. The key is to use antibiotics less, and to use the most effective ones most sparingly of all. And therein lies a paradox.

How can we get doctors and patients, farmers and veterinarians, to cut back on miracle drugs? How can we get pharmaceutical companies to develop newer and better drugs if the whole point is to save such drugs for treatments of last resort? Pharmaceutical companies are geared towards cashing in widely while a drug is still protected by patent, not storing up their product till it can be undercut by generics. Unsurprisingly, Hall et al. argue for greater regulation, taxation, public funding of research, and central, international planning.

Taxation is often preferable to regulation. The authors cite a recent EU ban on using antibiotics purely to foster growth in livestock. The ban had almost no effect, they say, because producers simply said they were using antibiotics for other purposes such as disease prevention. A tax on antibiotics, however, would constrain their use while leaving them affordable as a last resort if really needed to combat infection.

Such talk is anathema to our capitalist, neoliberal world. Taxes are always bad, and without an immediate profit incentive, we imagine that nothing could ever get done. (Certainly no windfall profits and spectacular stock growth could ever get done.) We imagine that the market will always generate solutions, but solutions to the problem of antibiotic resistance lie in restraint and throttling profits.

They also lie in infrastructure, traditionally the province of governments and also involving unpopular taxation. Too much of the world still lacks running water and proper sanitation. At the same time, in nations like India and China, antibiotics are widely available over the counter, and the environment teems with their components, which are manufactured there. Combined with endemic poverty, such places become a breeding ground for "superbugs."

What can we do? The authors argue for a restructuring of the pharmaceutical marketplace, greater investment in public health, and a few commonsense preventative measures that anyone can practice. Some form of nationalization is indicated, though suggested mechanisms vary. Unlike some other forms of drugs (cancer treatments, for example), antibiotics constitute a kind of infrastructure. Perhaps they need a different economic underpinning.

John Rex, one of the leading researchers in this field, argues that antibiotics provide coverage that is similar to that of a local fire brigade. … "When you pay the firefighters, do you pay them per fire, or do you pay them a salary?" (109)
Only by managing antibiotic production and use, the authors argue, can we provide modern medicine with the sine qua non for its more profitable innovations.

And the first-world consumer can do some basic stuff. Wash hands for at least 20 seconds, long enough to sing "Happy Birthday" twice. I tried this in the men's room at work this afternoon, but got embarrassed when somebody walked in. I have to learn to sing silently.

We should also not demand antibiotics when we are sick. We can buy meat and fish from sources that use antibiotics responsibly. (216)
Not demand them when we are sick? Heresy! But the authors point out that most illnesses go away, antibiotics are widely prescribed even if the cause of an illness is viral, and children are notoriously overdosed with them. Everyone should probably just suffer a little bit more. But doctors are wary of such suffering, particularly if they risk losing a patient by not dosing liberally and early on. Better diagnostics would help, but need direction and public support, lest the next Theranos rip us off in a vain search for them.

Washing hands is crucial, and I've certainly started to become more aware of this since reading Superbugs (though I always was a bit of a neat freak). Fox News anchor Pete Hegseth said recently that he hadn't washed his hands in ten years (I mean, how is that even possible? Does he not shower? Not shave?) It was perhaps a joke, but embodied an attitude that some individuals selfishly harbor. Hegseth argued that his germ-laden regimen toughened him up personally. But it's not about you, idiot. It's about the people whose hands you shake and whose stuff you touch. So too with antibiotic use. By saving ourselves a little trouble and pain, we may cost the world and our progeny the miracles we have always taken for granted.

Hall, William, Anthony McDonnell, and Jim O'Neill. Superbugs: An arms race against bacteria. Cambridge, MA: Harvard University Press, 2018. QR 177 .H35