Octavian Report: 2016’s Review on Antimicrobial Resistance predicts as many as 10 million annual deaths from AMR, the resistance of bacteria to antibiotics, by 2050. How credible do you find that estimate?
Laurie Garrett: I think it's reasonable, based on what we know about current AMR death rates -- which is that it's very confusing right now. Very, very few hospitals actually report AMR incidents. Private hospitals all over the world don't want anybody to know if they have such things going on because then likely patients will go to a different rival hospital. Many countries have no mandatory reporting at all, or the capacity to even track AMT incidents for lack of laboratory resources. And finally, the food industry tends as a rule to do their very utmost to have nobody know what they're finding in livestock or in poultry or in whatever it is they produce; they tend to kill the animals if they spot any drug-resistant bacteria in them without reporting it rather than risk having them get out into the food chain or risk a PR crisis.
So we often have no idea. If a college co-ed comes down with a urinary tract infection involving an E. coli strain that is multidrug-resistant, we don't know if it gets reported. If she just goes to the local clinic and gets treated, does anyone do a resistance assay? If it does get reported, does anybody link it to her food consumption and go back to the supermarket and determine what's going on? In general, the answer is no, no, and no. So to answer the question will it be 10 million, 100 million, or five million deaths from AMR annually by 2050, let me say that the problem is we don't even know how many millions are coming down with AMR-associated disease now. It's a very large number. We know that.
OR: What are the big socioeconomic drivers of AMR?
Garrett: The number-one problem, without a doubt -- and I mean log-scale number-one above everything else -- is the use of antibiotics as growth promoters in the livestock and aquaculture industry (and increasingly in crop farming as well). The industry will tell you that the compound they're putting routinely in the feed of every single chicken or every single cow or every single pig is not identical to an antibiotic available in your pharmacy. That it's one hydroxy group different or that it has an attached chlorine element. But the truth is they are in the body biologically identical, and the compounds used as growth promoters are directly responsible for a surging rate in antibiotic resistance.
In particular, as we noted in an expert brief that was posted on the CFR's website on this topic in April, we now have two broad classes of plasmids that have emerged. One class is known as the NDM or New Delhi Mutations. It was first noted in 2008 and is now pretty much everywhere in the world and has mutated into more than 19 subtypes. The other class is called MCR, first noted in China in about 2015. It has now already mutated into two subtypes and is seen in at least 31 countries -- including the United States.
These plasmids are transposable units that jump from bacterium to bacterium, from species to species. So they are, as we call them, promiscuous genetic elements. They're not confined to a given species line. They could spur very, very broad-spectrum resistance against a huge range of drugs, to the point of creating incurable diseases.
In both cases they've arisen out of the livestock industry in India and China, where the use of growth promoters is so ubiquitous and so completely unregulated that there are places in China where antibiotic-resistant plasmids come out of the water faucet and antibiotic residue comes out in drinking water. Where the rivers literally run with antibiotic resistance. We're really at a dire, dire turning point right now if we don't manage to take action well beyond the namby-pamby crap we've been saying for the last 20 years -- "Please doctors, minimize your use of antibiotics and prescribe appropriately." That's so 1980's. The situation is way beyond whether or not a given pediatrician overprescribes antibiotics. They are in the food chain, they are in the environment, they are in the water, they are in the air. We can show that antibiotic-resistant bacteria are carried in air streams and go from one part of the planet to another. It is out of control.
OR: Where geographically and with what particular bacteria might we expect a pandemic to begin?
Garrett: It doesn't work that way. Pandemics tend to be viral, and that's because viruses transmit completely differently. The whole problem with antibiotic resistance, the reason it hasn't been taken seriously, the reason the livestock industry has gotten away with destroying the antibiotic revolution, is because it creeps and crawls and slowly acquires in any given bacterial species, in any given setting, in any given food or hospital or geography. What we've seen is a steady march towards disaster, towards apocalypse, but it's decades in the making. When you get to the level of senior policy, of legislators, of presidents, all problems that grow incrementally draw less attention because they don't look as urgent as problems that suddenly flash (like an Ebola epidemic). It's not a pandemic that will arise. Bacteria are so resilient, so mutable, so capable of altering their entire evolutionary course that we're seeing dramatic changes in bacterial populations all over the world already.
Let's look at it this way. Before the age of antibiotics, my aunt in the 1920's scraped her knee and got an infection that went into the bone and resulted in osteomyelitis. She was a child; it must have been excruciatingly painful. For the rest of her life she walked with a limp and with difficulty. Most people assumed she had been a polio victim. But it was because antibiotics didn't exist. This routine scratch of the knee crippled her for life.