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Some peo­ple de­scribe Dar­winian evo­lu­tion as “only a the­ory”. Try ex­plain­ing that to the friends and rel­a­tives of the 700,000 peo­ple killed each year by drug-re­sis­tant in­fec­tions.

Re­sis­tance to an­timi­cro­bial medicines, such as an­tibi­otics and an­ti­malar­i­als, is caused by the sur­vival of the fittest. Un­for­tu­nately, fit mi­crobes mean un­fit hu­man be­ings. Drug-re­sis­tance is not only one of the clear­est ex­am­ples of evo­lu­tion in ac­tion, it is also the one with the big­gest im­me­di­ate hu­man cost. And it is get­ting worse. Stretch­ing to­day’s trends out to 2050, the 700,000 deaths could reach 10m. Cyn­ics might be for­given for think­ing that they have heard this ar­gu­ment be­fore. Peo­ple have fret­ted about re­sis­tance since an­tibi­otics be­gan be­ing used in large quan­ti­ties dur­ing the late 1940s.

Their con­clu­sion that bac­te­rial dis­eases might again be­come epi­demic as a re­sult has proved false and will re­main so. That is be­cause the de­cline of com­mon 19th­cen­tury in­fec­tions such as tu­ber­cu­lo­sis and cholera was thanks to bet­ter hous­ing, drains and clean wa­ter, not peni­cillin. The real danger is more sub­tle—but grave nonethe­less. The fact that im­prove­ments in pub­lic health like those the Vic­to­ri­ans pi­o­neered should even­tu­ally drive down tu­ber­cu­lo­sis rates in India hardly makes up for the loss of 60,000 new­born chil­dren ev­ery year to drug-re­sis­tant in­fec­tions. Wher­ever there is en­demic in­fec­tion, there is re­sis­tance to its treat­ment.

Com­mon fail­ings

The spread of re­sis­tance is an ex­am­ple of the tragedy of the com­mons; the costs of what is be­ing lost are not seen by the peo­ple who are re­spon­si­ble. You keep cat­tle? Add an­tibi­otics to their feed to en­hance growth. The cost in terms of in­creased re­sis­tance is borne by so­ci­ety as a whole. You have a sore throat? Take an­tibi­otics in case it is bac­te­rial. If it is vi­ral, and hence un­treat­able by drugs, no harm done—ex­cept to some­one else who later catches a re­sis­tant in­fec­tion. The lack of an in­cen­tive to do the right thing is hard to cor­rect. In some health-care sys­tems, doc­tors are re­warded for writ­ing pre­scrip­tions. Pa­tients suf­fer no im­me­di­ate harm when they ne­glect to com­plete drug cour­ses af­ter their symp­toms have cleared up, leav­ing the most drug-re­sis­tant bugs alive. Be­cause many peo­ple mis­tak­enly be­lieve that hu­man be­ings, not bac­te­ria, de­velop re­sis­tance, they do not re­alise that they are do­ing any­thing wrong.

Sugar the pill

Be­cause an­timi­cro­bial re­sis­tance has no sin­gle so­lu­tion, it must be fought on many fronts. Start with con­sump­tion. The use of an­tibi­otics to ac­cel­er­ate growth in farm an­i­mals can be banned by agri­cul­ture min­istries, as it has in the Euro­pean Union. All the bet­ter if gov­ern­ments jointly agree to en­force such rules widely. In both peo­ple and an­i­mals, pol­icy should be to vac­ci­nate more so as to stop in­fec­tions be­fore they start. That should ap­peal to cash­strapped health sys­tems, be­cause pro­phy­laxis is cheaper than treat­ment. By the same logic, hos­pi­tals and other breed­ing grounds for re­sis­tant bugs should pre­vent in­fec­tions by prac­tis­ing bet­ter hy­giene. Gov­ern­ments should ed­u­cate the pub­lic about how an­tibi­otics work and how they can help halt the spread of re­sis­tance. Such poli­cies can­not re­verse the tragedy of the com­mons, but they can make it a lot less tragic.

Pa­tients suf­fer no im­me­di­ate harm when they ne­glect to com­plete drug cour­ses af­ter their symp­toms have cleared up, leav­ing the most dru­gre­sis­tant bugs alive.

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