I’ve suggested that antibiotic resistance will lead to improvements in healthcare: when hospitals cannot reliably treat infections, they are forced to prevent them (which they should have been doing all along). That change in emphasis necessarily requires a change in culture. Infection treatment is largely driven by individual practitioners, but effective infection prevention requires cooperation and coordination at all levels of the medical establishment, from the C-suite down to the orderlies. Infection control is a communal activity and its success is highly dependent on organizational culture.
What’s true of hospitals is true of society at large. Countries that value their citizens provide them with healthcare. They spend money not just on hospitals and doctors, but on public health measures like vaccines and clean water. Or, leaders view their citizens as so much livestock to be milked and shorn and then left to fend for themselves. We shouldn’t be surprised if bacteria, opportunistic as always, take advantage of weak social systems.
A comprehensive look at worldwide antimicrobial resistance makes the case that social factors drive resistance rates. The authors created a dataset of social indicators for 103 countries, and used these data in a multivariate analysis to identify the factors that correlate most strongly with resistance. “Correlate”, is of course the key term here; any claims to causality are speculative. Here is what they found:
Surprisingly, the analysis finds that per capita antibiotic consumption has little effect on resistance rates. This makes little sense from what we know of the biology of resistance; and it also contradicts findings from previous studies, for example:
I suspect the explanation lies in the source data, which estimates antibiotic consumption from the volume of antibiotics sold in retail and hospital pharmacies. Street sales–not to mention livestock use, which accounts for the bulk of antibiotic sales in the US–are left out.
However, the correlation of government corruption with resistance is strong and positive, while spending on healthcare and infrastructure show strong negative correlations. In other words, the health of a country’s civic life appears to have a direct impact on its ability to control the spread of resistant bugs. Less money lost to corruption results in more money available to provide clean water and food (thus preventing infections) and for clinics and hospitals to treat infections appropriately.
Counterintuitively, higher levels of education and income correlate to more resistance. I suppose either of these factors could lead to greater demand for antibiotics, either directly or indirectly, such as through greater demand for elective surgery.
That’s all speculation. The real import of this paper is not to suggest specific causes or solutions to the problem of antibiotic resistance. Instead, it frames resistance in a larger social context and suggests we need to look beyond purely medical or pharmacological approaches.
There was a time when resistant bugs were rarely found outside hospitals. Hospital-centered approaches might have contained them then, but that opportunity is long past. Bad governance results in bad bugs. We can’t contain the latter without fixing the former. Antibiotic resistance is a social disease.