Antibiotics: A Broken Promise

A few decades ago the development of antibiotics led many people to believe that the threat offered by infectious diseases had, to a large extent, been conquered.

But a combination of greed and stupidity has changed all that. The effectiveness of antibiotics has been dramatically weakened by three main groups: the companies making them, the medical profession and the farming industry. Each of these groups has acted irresponsibly and dangerously. Since they cannot possibly have been unaware of the impact their actions would have it is impossible to avoid the conclusion that the effectiveness of antibiotics has been deliberately destroyed for short term profit. The drug companies, the medical establishment and the farming industry will together be responsible for millions of deaths. The politicians who have stood to one side and allowed all this to happen must share the responsibility.

The destruction of antibiotics as a weapon in the fight against infection is not a reason why we are now more vulnerable to infection. But it is an important reason why the number of people dying from infections is rising - and will rise dramatically during the next decade or so.

The introduction of antibiotics, just half a century or so ago, led many people (including most doctors) to believe that infectious diseases had been defeated.

But during the last two decades simple, widespread infections have been striking back and once again re-establishing themselves as serious threats to our health - as serious as cancer and heart disease.

In 1952 virtually all infections caused by staphylococcus could be cured by penicillin. But by 1982 a worrying 90% of patients infected with the staphylococcus bug needed treatment with other antibiotics. Penicillin - the best known, cheapest and most widely available antibiotic in the world - no longer worked against staphylococcus.

Doctors didn't worry about this because they had other antibiotics to prescribe. With remarkable arrogance the medical profession assumed that it could always stay one step ahead of the bugs.

What many doctors failed to realise was that yeasts, fungi and bacteria have been producing antibiotics more or less since time began. They use the antibiotics they make to protect themselves. Other yeasts, fungi and bacteria mutate naturally in order to protect themselves against those antibiotics. Through a mixture of ignorance and arrogance doctors speeded up the rate at which bugs acquired resistance by spreading antibiotics around with reckless abandon.


The Staphylococcus Story

The staphylococcus bug is widespread and constantly being passed from one person to another. It is possible to pick up staphylococcus simply through a handshake. It also affects some mammalian pets and so can be picked up that way too.

Most of the time the body's immune system deals with the bug fairly quickly and effectively. The staphylococcus only becomes a real problem when it is picked up by a human being with a wound of some kind - or an immune system that is out of condition or already stretched so much that it cannot cope. Under those circumstances the staphylococcus can kill.

In order to try to stop staphylococcus bugs causing so many deaths in hospitals doctors started routinely giving antibiotics to all the patients whom they thought might be at risk - and this category naturally included all those patients who were destined for surgery.

The prescribing doctors either didn't realise or didn't care that by dishing out antibiotics so freely they were giving the bugs a greatly increased chance of acquiring immunity.

Staphylococcus has not, of course, been the only bug to become resistant. In 1990 Jim Henson, the inventor of TV puppet stars the Muppets, died of a new, resistant streptococcal infection. Doctors suddenly started to report the existence of antibiotic resistant strains of streptococcus pneumoniae - which were new enough and virulent enough to kill individuals with weakened immune systems.

Leprosy, easily treated until the late 1970s, became a major problem again when a new, resistant type of the bacterium mycobacterium leprae appeared in Ethiopia. Gonorrhoea acquired worldwide resistance to penicillin and other drugs. By 1990 eight out of ten illnesses caused by shigella were resistant to antibiotics. Malaria, apparently almost under control in the 1950s, has become a major killer because of the drug resistant plasmodium falciparum parasites. Tuberculosis, still apparently regarded by many doctors as a disease of the 19th century, has come back with a vengeance with the development of a drug resistant strain. UNICEF is now warning that antibiotic resistant strains of tuberculosis need to be taken seriously. Tuberculosis kills over three million people every year. I have been warning about the resurgence of tuberculosis since the early 1990s.

Throughout the early 1990s doctors in the developed world tried to combat new outbreaks of infectious disease by prescribing antibiotics in ever increasing quantities. They also tried to protect patients against infection by prescribing antibiotics for healthy patients. Naturally enough the drug industry, which was making huge profits out of the sale of antibiotics, did not object to this. Politicians, constantly afraid of offending the drug companies, did everything they could to stifle protests by people like me who wrote about this problem and warned about the future consequences.

In the developing countries, where doctors were not always available, patients simply bought their own antibiotics. (Ironically - and in my view with considerable cheek - some observers in the developed world are now blaming the overuse of antibiotics in the developing world for the fact that new antibiotic resistant bugs are now a serious worldwide threat.)

Today the future is truly bleak. Infectious diseases which we thought we had conquered are coming back with a vengeance. More and more people are dying of simple, uncomplicated infections. The bugs are getting stronger. And our ability to zap them is diminishing almost daily.


The Overprescribing Of Antibiotics

I have, for many years, written about the way that doctors do harm by over-prescribing. The best example of the modern tendency to over-prescribe probably lies in the way that antibiotics are used. One in six prescriptions is for an antibiotic and there are at least a hundred different antibiotics available for doctors to choose from.

When antibiotics - drugs such as penicillin - were first introduced in the 1930s they gave doctors a chance to kill the bacteria causing infections. My educated guestimate is that for several decades between half and three quarters of all the prescriptions written for antibiotics have been unnecessary or inappropriate. That is still the situation today.

To a certain extent doctors over-prescribe because they like to do something when faced with a patient - and prescribing a drug is virtually the only thing most of them can do. Prescribing a drug is also a defence against any possible future charge of negligence (on the basis that if the patient dies it is better to have done something than to have done nothing).

But the main reason for the over-prescribing of antibiotics is, without doubt, the fact that doctors are under the influence of the drug companies. The makers of the antibiotics want their drugs prescribed in vast quantities. It makes no difference to them whether or not the prescriptions are necessary. There is now no doubt that many of our most useful drugs have been devalued by overuse and are no longer effective.

Doctors regularly hand out these potentially life-saving pills for minor coughs and infections that would have got better anyway within days. Colds and flu are caused by viruses - which are not susceptible to antibiotics.

The excessive quantities of antibiotics we have swallowed by the ton have weakened our general resistance to infection and paradoxically, strengthened the power of the bugs.

The existence of many antibiotic resistant organisms is the main reason why infections are such a major problem in hospitals. Alarmingly, at least 1 in 20 of all hospital patients will pick up an infection in hospital - mostly urinary tract, chest or wound infections. Bizarrely, the spread of these antibiotic resistant organisms is mostly caused by doctors and nurses failing to wash their hands often enough. Since Ignaz Philipp Semmelweiss first demonstrated (in the mid-19th century) that deaths in the delivery room were caused by dirty hands every child has been taught the importance of basic personal hygiene. Sadly, the message does not seem to have got through to the medical and nursing professions. Several recent studies have shown that neither doctors nor nurses wash their hands anywhere near as often as they should. At least one-third of all hospital infections are caused by dirty hands and the cost in simple financial terms is colossal (though not, of course, as horrendous or as unforgivable as the cost in human terms). It is hardly surprising that people who stay at home to be treated - or who go home quickly after day-case or short-stay surgery - usually get better much quicker than people who need long-stay treatment.


The Emergence Of Superbugs

By the mid 1980s it was already becoming clear that all this bad prescribing was causing serious problems. Strains of staphylococcus were appearing which were resistant to many antibiotics.

At first the new superbugs only caused problems within hospitals - where they caused many deaths among patients whose immune systems had been compromised by other diseases or by physical or mental stresses. It was in hospitals that many superbugs first started to appear but by the early 1990s the staphylococcal superbugs were appearing inside and outside hospitals all around the world.

The problem was so great that the extra costs incurred when doctors had to prescribe increasingly expensive antibiotics was beginning to add an enormous burden to all those responsible for providing health care facilities. In America the extra cost of dealing with antibiotic resistant organisms was, by the end of the 1980s, estimated at being in excess of $30 billion a year.


The Threat of Salmonella

Salmonella became a more or less untreatable disease in 1993 and now poses a serious health threat. According to the U.S. Department of Agriculture 661,000 people are made ill every year by salmonella-infected eggs. Of those around 400 people die. The Department of Agriculture's original count was considerably higher. The figure of 661,000 was obtained after a recount. I don't have any figures I trust for any other country. In the U.K. I certainly wouldn't trust any figures produced by the Ministry of Agriculture and Fisheries.

The big problem with salmonella bacteria is that some strains are already resistant to ampicillin, streptomycin, tetracycline, sulphonamides and chloramphenicol. It won't be long before some salmonella bacteria are resistant to all known antibiotics. When that happens the death rate from salmonella will rocket.

Most salmonella antibiotic resistance develops on farms where half of all antibiotics produced are used (I will explain why in a moment or two). Naturally, the salmonella bacteria in chickens affect the flesh of the birds as well as their eggs. And the bacteria can easily spread from chicken flesh to other products.

My informed and considered view is that if you are an egg eating heterosexual and you don't mainline illegal drugs with dirty needles then you are more likely to contract and/or die of salmonella poisoning than you are to contract and/or die of AIDS. Moreover, there seems little doubt that unless the mass use of antibiotics on farms is stopped then salmonella poisoning will pose a considerably greater threat to future generations of the human race than AIDS. Nevertheless, I have no doubt that governments will continue to spend billions on researching still fashionable AIDS but will not risk offending the rich farming lobby by suggesting that antibiotic use be reduced.


Irresponsible Farmers

Partly thanks to doctors and drug companies the future is truly bleak. Infectious diseases which we thought we had conquered are coming back with a vengeance. More and more people are dying of simple, uncomplicated infections. The bugs are getting stronger. And our ability to kill them is diminishing almost daily.

Scientists messing around with genes are making things considerably worse and ensuring that the future is even more bleak than the present.

However, it is the overuse of antibiotics by farmers which is one of the main reasons why infectious diseases are making a dramatic comeback. Farmers are going to be directly responsible for millions of deaths.

Astonishingly, considerably more than half of all the antibiotics sold are given by farmers to healthy animals. Giving antibiotics helps improve the size and therefore the value of animals. I first wrote about this grossly irresponsible but profitable habit back in the 1970s but politicians have steadfastly refused to take on the farming community and stop farmers using antibiotics.

Why do farmers give their animals so many antibiotics?

Well, to start with, farmers give some antibiotics to animals to help prevent (and treat) disease. Animals on modern farms are exceptionally susceptible to disease because they are kept in overcrowded conditions and they are constantly highly stressed. Antibiotics help to keep sick animals alive long enough to be slaughtered and fed into the food chain. Antibiotics are also given because they help to stop diseases spreading quickly among animals who are kept in cramped and entirely unnatural conditions. When animals live in hideously confined quarters it is nigh on impossible to stop infections spreading without using antibiotics.

Many farmers also routinely put antibiotics into the feed they give their animals to prevent infections developing and the antibiotics that are dished out in this grossly irresponsible way are often the same antibiotics that are becoming dramatically less effective in the treatment of human diseases.

But farmers don't just give antibiotics to animals in order to deal with disease. It was reported in 1998 that some 10,000 pig, poultry and beef farms in Britain alone were mixing antibiotics into their animal feed in order to promote growth.

Back in the 1940s it was noticed that animals who were regularly given antibiotics put on weight more rapidly than animals who weren't. I don't think anyone knows why this happens but antibiotics increase the muscle bulk of animals - and therefore increase their value and the farmer's eventual profit. Despite the fact that antibiotic resistance was, even then, acknowledged to be a problem, farmers started to give their animals antibiotics in order to increase their profits. To their eternal shame vets and politicians succumbed to pressure from the farmers and allowed this to happen. (In an attempt to disguise their guilt - and to hide what they are doing - farmers describe the antibiotics they give to animals as`digestive enhancers'.)

Amazingly, farmers do not need a prescription from a vet in order to give antibiotics to their animals on a regular, daily basis. You need to visit a doctor to get an antibiotic if you have an infection which needs treatment. But farmers can buy their antibiotics in bulk - and throw them into the animal feed by the fistful.

Of course, there have over the years been a few pretty half hearted attempts to stop this grossly irresponsible practice. Various committees and organisations (including the World Health Organization) have recommended phasing out the routine use of antibiotics as growth enhancers.

(I am afraid I cannot explain why `phasing out' has been recommended instead of simply halting this outrageous practice - though undoubtedly the power of the farming industry has much to do with this.)

In December 1998 the European Union finally proposed a ban on the use of some antibiotics by farmers. The British government said it would probably support such a ban but it was clear that any such move would probably prove pointless when drug companies said they would challenge any such ban in the courts. A legal battle on such a complex issue would, with all the appropriate appeals, probably last for at least a decade. In the end the EU announced with a great fanfare that it had banned farmers from using just four antibiotics. But they did not introduce a general ban on the use of the tetracyclines and penicillins - the drugs which are most commonly used both on animals and for human patients. In my view this was akin to making murder illegal between 10.45 pm and 10.50 pm on alternate Wednesdays.

The process by which antibiotic resistance develops is simple to explain. When animals are given antibiotics the bacteria in their intestines build up an immunity to those antibiotics. Those antibiotic resistant organisms then pass on to farmers and others who have contact with the animals. They pass into the environment (even though most animals are denied access to fields their faeces and urine still reach the environment when they are dumped onto fields or discharged into rivers). And, of course, the antibiotic resistant organisms pass into the food chain directly when animals are killed, chopped up and eaten by humans. When milk in the US was tested researchers identified 52 different antibiotic residues.

As if all this wasn't bad enough there is also evidence that the antibiotic resistant organisms can pass their resistance on to other, more dangerous bacteria. There are already some dangerous infections which are virtually untreatable because the bugs involved are resistant to all the available antibiotics.


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