By Craig Moran
When penicillin was first made commercially available in 1942, it was seen as a near panacea that would save lives and limbs from bacterial infections. No longer were patients living in fear of losing a leg from an infected wound or dying from pneumonia. Even so, after collecting his Nobel Prize in 1945 for its discovery, Sir Alexander Fleming warned that overuse would eventually render penicillin useless as bacteria evolve to resist to the drug. Unfortunately, his warnings went unheeded. After decades of over-prescription, we now find ourselves at such a critical juncture that this year’s U.N. General Assembly recently labeled the rise of antibiotic-resistant bacteria (AMR) “the greatest and most urgent global risk,” trumping even climate change.
Can the U.N. and its committees rise up to the challenge and tackle AMR? While health bodies including the World Health Organization have been sounding the alarm about the threat posed by AMR to public health for two decades, market forces have kept antibiotic usage rates high. In agriculture, they are administered to animals not just to treat infections, but also to make them grow bigger—a practice condemned by health officials. From there, water and fertilizer containing antibiotics are sprayed on crops, providing the means by which antibiotics and resistant bacteria enter the food supply. A second cause for the rise of AMRs is through the over-prescription of antibiotics by doctors who too often give in to pressure from their patients, even in cases where no bacterial infection is present. In the United States alone, a full 30 percent of antibiotics prescribed are unnecessary, adding up to 47 million excessive—and harmful—prescriptions.
Nowhere is this problem more acute than in sub-Saharan Africa. One study, assessing 141,000 patient visits to 572 primary care centers in 11 African countries, found that in nearly half of these visits the patient received antibiotics, as opposed to the one in three recommended by the WHO. Drug-resistant strains of tuberculosis are reaching alarming levels; one Cameroonian survey found multidrug resistant TB in 27 percent of patients who had previously been treated for the disease. The spread of another “nightmare bacteria” known as CRE has been tracked in South African hospitals. In 2012, 64 patients tested positive for the superbug; just three years later, that number was 587. Poorly developed health care systems compound the problem, as does the fact that many Africans who lack access to adequate health care turn to unsanctioned providers offering shoddy drugs.
In Africa, where the fight against AMRs is most urgent, the WHO’s preparedness to lead is most in question. These reservations largely stem from the organization’s structural shortcomings, which were revealed by its slow response to the Ebola outbreak. Even though the first cases of the disease were reported in Guinea in December 2013, it wasn’t until August 2014 that the WHO finally announced the world was facing an outbreak of international concern. This came only after nearly 1000 deaths and months of pressure from groups like Doctors Without Borders. A WHO internal document blamed incompetent staff for “fail[ing] to see some fairly plain writing on the wall.” Subsequent revelations show that the recruitment process for the Republic of Congo-based Africa office was highly politicized, with directors elected by African health ministers. That process rendered the directors unduly dependent on support from their patrons in order to function.
Why does this matter? When a public health issue becomes a global threat, it’s up to the WHO to lead the charge to fight it. This has been the case with other global pandemics such as AIDS or SARS. Having seen how poorly Ebola was handled, it’s unclear whether the WHO can respond to the obvious urgency of fighting AMR.
One of the WHO’s glaring structural weaknesses is that it is wholly dependent on national donors to function. At the same time, the WHO is supposed to regulate and instruct national policymakers on how best to tackle health care reform. Through this setup, the influence individual countries can exercise over global health policy is obvious. Despite extensive evidence of the adverse effects of herbal medications, the WHO conceded to the demands of two of its biggest members, India and China, to push for the integration of traditional medication into national health care provision. The fact that both of these countries have large traditional medicinal industries that stood to profit from the WHO’s stamp of approval is illustrative of how easily the organization can be compromised. With its budgets been slashed repeatedly—decreasing by more than 20 percent over the last few years—the WHO is in no position to pick fights with governments, several of which are major producers of antibiotics.
There is more than political interference to blame for the WHO’s often-unsound judgment. Its stance on e-cigarettes is another worrying example of the organization adopting unscientific positions. Despite the Royal College of Physicians’ conclusion that electronic cigarettes are 95 percent safer than tobacco, the WHO, through its Framework Convention on Tobacco Control, has nonetheless decided to essentially treat them the same tobacco cigarettes are treated, advocating for strict regulation. Such an approach is counterproductive to the FCTC’s own aims to protect people from the devastating “health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke”.
The WHO’s problems are not entirely of its own making, and like most U.N. bodies, it is perennially underfunded. There is a strong argument to be made that the organization has become overstretched and ossified in its operations. One solution to this problem could lie in allowing more nimble organizations like Doctors Without Borders, the Bill and Melinda Gates Foundation, or the International Rescue Committee to take the lead, with the WHO playing a coordinating role. Given the speed with which a health crisis can erupt and spread in a deeply interconnected world, it is in no one’s interest to rely on a cumbersome first responder.
Craig Moran is an independent geopolitical consultant. He has experience in energy and natural resources planning, assessing and advising on political and security risks, and handling constitutional and legislative issues across multiple territories.
[Photo Courtesy of David Mark]