Why should the United States care about health problems in distant, poor countries when there are pressing priorities here at home? It’s a classic question. People trying to influence policy have never trusted humanitarianism to carry the day and have instead appealed to the self-interest of U.S. citizens. When it comes to health, U.S. travelers heading to foreign lands for tourism or work need protection from disease or at least the promise of a cure when they return home. Of utmost concern, the military sends large numbers of troops where they are in danger not only from armed conflict, but also from exotic (and often dangerous) diseases.
But no tropical disease can make as clear a case for U.S. self-interest as antibiotic resistance can: witness the furor over NDM-1—the resistance gene that seems to have arisen in patients on the Indian subcontinent. Was the furor over a health problem in India and Pakistan? No. The news that hit U.S. and European newspapers was over the report about NDM-1 in Lancet Infectious Diseases that identified people in England who had had surgery in India—“medical tourists”—as victims, and warned that the UK National Health Service might suffer financially because patients coming home had to be hospitalized and treated with expensive antibiotics to cure their infections. These just as easily could have been Americans—and now they are: NDM-1 was found in three U.S. medical tourists (and one Japanese man) on their return from India.
Unlike malaria and other “tropical” diseases, the same species of bacteria are distributed worldwide. The risk of resistant organisms moving from one country—or continent—to another is just a matter of chance. Odds are that with one billion people crossing borders every year, antibiotic resistance is bound to travel too, and if it’s the right type, it will be sustained and able to spread wherever it lands. It’s worth remembering that the genetic elements that make for antibiotic resistance can just as easily be carried by nonpathogenic bacteria—the “good” ones living in and on us all the time—as by the pathogenic bacteria that make us sick. And that those genetic elements are often quite mobile, being traded between unrelated types of bacteria. They’ll eventually end up where they are least welcome—in surgical wounds or catheter-related infections in hospitals, for instance.
The point is that antibiotic effectiveness is a shared global resource: antibiotic use anywhere affects the ability of others to use antibiotics in the future everywhere. Antibiotic resistance won’t be stopped by stricter visa requirements, nor is screening a realistic option. The United States is as likely, or even more likely (compared with some European countries), to be a source for antibiotic resistance as it is to be the recipient. For the most part, people in the United States and other rich countries may be inconvenienced, and some will actually be hurt or killed by antibiotic-resistant bacteria, but most will be cured after treatment with more expensive antibiotics. And transmission of those bacteria will be curtailed because of successful treatment.
In poor countries, more expensive antibiotics are not available for most of the population, so more people do die. Those who survive may remain infected longer, may transmit the resistant bacteria to others more readily, or may retain the genetic elements responsible for resistance in their good bacteria, to be passed on later. The hardship is borne locally, and we should care about that, but we should also care that resistance can grow and spread globally.
The good news (and we need some) is that antibiotic resistance can be slowed through available measures that are affordable everywhere. The best approach is to reduce the need for antibiotics by reducing the incidence of infection. Vaccines against the most common causes of childhood pneumonia—Haemophilus influenzae type b and Streptococcus pneumoniae—are available, and funds to defray their cost in low-income countries are available from the Global Alliance for Vaccines and Immunization (GAVI). Infection control in hospitals starts with something as simple as frequent handwashing by healthcare staff and family members. Getting people to wash their hands, and take other measures, requires education and an appreciation for infection control. This is feasible but not always easy.
For reasons that are not fully understood, some strains of resistance die out, some remain local, others go global, and some circulate for many years or decades. NDM-1 is worrisome because it can be transmitted by several genetic mechanisms and it already has crossed international borders. Whether it poses a unique threat or is just one more among many is not known at present. The best we can hope for is that NDM-1 itself dies out but that heightened awareness of antibiotic resistance as a global concern, and the will to address it, remain.
Ramanan Laxminarayan directs Extending the Cure, a research and consultative effort that frames the growing problem of antibiotic resistance as a challenge in managing a shared societal resource. Extending the Cure is funded in part by the Robert Wood Johnson Foundation (RWJF) through its Pioneer Portfolio and is a project of the Center for Disease Dynamics, Economics & Policy. The Pioneer Portfolio at RWJF powers ideas to transform health, seeking breakthroughs with the potential to generate significant health and social impact.
Hellen Gelband is the Project Coordinator for the Global Antibiotic Resistance Partnership (GARP), which is developing actionable policy proposals on antibiotic resistance in China, India, Kenya, South Africa, and Vietnam. GARP is a project of the Center for Disease Dynamics, Economics & Policy.