In November 2013, Natalie Beatty, a 37-year-old Australian living in Hong Kong, noticed some small red lumps on her right foot and leg.
“At first I thought they were mosquito bites but when they started to swell, I headed to hospital.” A doctor prescribed antibiotics, and sent her home. The next day, the lumps had swollen into egg-shaped boils. “The largest one, on top of my foot, was the size of a mango cut in half.”
Beatty returned to hospital. The doctor lanced the biggest boil (“Loads of gunk came out. It was like something out of the movie Alien”) and took a swab for analysis.
“He called the next day and told me I had contracted MRSA,” Beatty recalls. “He advised me to google it, and then come straight back to hospital.” What she read horrified her. “It’s a race against time to get the right antibiotics to fight the infection because if it spreads to your bones, blood or brain, you could die or end up severely handicapped.”
MRSA – the common name for the Methicillin-resistant Staphylococcus aureus bacteria – is a “superbug”. Responsible for about 250 deaths a year in Hong Kong, it is resistant to multiple classes of antibiotics. You can catch it through contact with an infected person or a bacteria-smeared object. In Beatty’s case, the doctor thought she might have picked it up during a foot massage. Fortunately, the next course of antibiotics she took proved effective, and she was restored to full health.
At the United Nations’ General Assembly in New York, in September, the emergence of drug-resistant superbugs, such as MRSA, was described as “the greatest and most urgent global risk”.
Opening the meeting, UN Secretary General Ban Ki-moon said, “In all parts of the world, in developing and developed countries, in rural and urban areas, in hospitals, on farms and in communities, we are losing our ability to protect both people and animals from life-threatening infections.”
Margaret Chan Fung Fu-chun, the World Health Organisation’s director general, called for “swift, effective, life-saving actions across the human, animal and environmental-health sectors”.
Since Alexander Fleming’s discovery of penicillin, in 1928, antibiotics have transformed society by saving countless millions of lives. But as bacteria evolve and become resistant to them, these miracles of modern medicine are rapidly losing their potency. The kicker is that the more antibiotics we use, the faster bacteria acquire resistance.
We cannot rely on pharmaceutical companies to develop new antibiotics – rates of discovery have dropped precipitously since the 1980s. Scientists across the globe are searching for cures. Some therapies show potential and might one day offer an alternative to antibiotics but, for the time being, there is nothing that can take their place.
A POST-ANTIBIOTIC FUTURE is a terrifying prospect. Experts warn of a looming apocalypse in which drug-resistant superbugs run rampant, overshadowing the threats of terrorism and climate change to become the most serious crisis of all. Already, 700,000 people die from drug-resistant infections every year. A report published by the British government and Wellcome Trust, in May, estimates that by 2050, that figure will have increased to 10 million – more than the number who die from cancer.
Without antibiotics, tuberculosis, pneumonia and gonorrhoea will become mortal threats. Pick up a dose of E. coli on a Hong Kong beach, or get a massage from the wrong person, and you might die. Antibiotics are also vital for preventing, as well as curing, infections – without them childbirth becomes high risk, routine surgery is life threatening and organ transplants are an impossibility.
That doomsday scenario edged closer to reality in November 2015, when scientists working in China – the world’s leading producer and consumer of antibiotics – discovered a gene called MCR-1 in bacteria from livestock and hospital patients.
MCR-1 gives bacteria resistance to an antibiotic called colistin,” says Professor Timothy Walsh, from Cardiff University, who collaborated on the study.
The news made headlines around the world. Colistin is a vital drug because it is (or was) the only option for fighting bacteria that have become resistant to every other antibiotic used by the medical profession.
Up until a few years ago, a group of antibiotics called the carbapenems, nicknamed “the big guns”, could be relied upon in extreme circumstances. But, in 2009, Walsh and his team detected bacteria containing a gene that confers resistance to carbapenems, meaning they are no longer failsafe.
“Now that carbapenems are compromised, we urgently need to reactivate colistin for use,” Walsh says, “but MCR-1 is spreading rapidly.” It is only a matter of time before bacteria that cannot be stopped by carbapenems, colistin, or anything else in the medicine cabinet, emerge. “It’s inevitable,” he says.
Colistin causes kidney damage, so it has never been popular with doctors. It has, however, been used in huge quantities by Chinese farmers.
On modern farms – in China and the rest of the world – animals are housed in overcrowded conditions. Outbreaks of infections are a constant risk so, although most farmers have no veterinary training, livestock feed is loaded with antibiotics to keep the herd healthy. Antibiotics also boost growth rates, fattening the animals and increasing yields for farmers. The use of antibiotics as growth promoters has been banned in the European Union, but not in the United States and China.
Agricultural antibiotics contaminate meat, encourage the emergence of drug-resistant bacteria in animals, and infiltrate soil and watercourses, accelerating the development of resistance in the environment.
“It’s easy to be critical of China with some degree of justification, but the Chinese were not acting irrationally,” Walsh says. “They didn’t use colistin in hospitals, so felt free to use it in agriculture. It was perfectly sound thinking during the era in which we had other antibiotics that could be used effectively on human patients.”
Three months ago, Beijing unveiled a National Action Plan designed to clamp down on overuse of antibiotics. Colistin will be banned as a growth promoter although it will still be permitted as a medicine in animals, in line with European policy. Given its importance, Walsh would prefer to see a global blanket ban.
“If a farmer buys colistin, lawfully, to treat a sick herd, he might be tempted to start adding it to feed if the animals’ weight drops. Most farmers don’t understand the consequences, and their priority is to provide a livelihood for their families.” He says enforcement will be particularly challenging in China. “The farming community is huge and constantly shifting. A blanket ban would make life a lot easier.”
At the time of writing, colistin was still freely available for sale, by the bucketful, on the Alibaba e-commerce portal.
Professor Yuen Kwok-yung, chair of infectious diseases at the University of Hong Kong, says that although reducing the use of antibiotics in agriculture is critical, it’s not something Hong Kong has much say in – because we have so few farms.
“We produce less than 1 per cent of our own food. The vast majority is imported, from China and other countries. We can’t control the use of antibiotics on the farms that supply us.”
So what can we do?
YUEN SAYS WE CAN REDUCE the risk of getting infections by “changing how we sell, store and cook food”. As a member of the Hong Kong government’s newly created High-Level Steering Committee on Antimicrobial Resistance, he hopes to develop strategies to clean up the handling of meat in wet markets, and educate the public on minimising the risk of contamination at home.
Consumers can sometimes wield more power than governments. Under pressure, McDonald’s recently committed to stop selling chicken raised with “antibiotics that are important to human medicine” in the US and Canada. In Denmark, a pork producer called Danish Crown has had tremendous success marketing pigs raised without any antibiotics at all.
Last year, Hong Kong’s Consumer Council wrote letters to nine of the territory’s largest fast-food chains, inquiring about their purchasing policies and urging them to devise plans to phase out food containing antibiotics. The council subsequently met with representatives from seven of the companies. The response from most was lukewarm.
“These are big businesses and even with goodwill, it takes a long time for them to make changes,” says Gilly Wong Fung-han, chief executive of the Consumer Council. “We will have to be very persistent in pursuing this campaign and we’ll gradually increase the pressure.” She expects support from the public. “Awareness is growing and people always prefer safer products.”
Livestock farming accounts for 50 per cent of antibiotics used globally. The other half is consumed by people. In terms of overuse, how does Hong Kong measure up?
Ho Pak-leung, a microbiologist at HKU, says public-sector hospitals are heavily regulated and use of antibiotics is tightly controlled.
“The incidence of resistant infections is rigorously scrutinised, and many practical solutions, such as training doctors on updated antibiotic protocols and hand-hygiene methods, have been implemented.”
The Hospital Authority’s computer server monitors drug prescriptions in real time, and picks up on any irregularities.
The private sector has a markedly different reputation, and is largely unregulated, especially at the primary-care level. There is no system for collecting data on prescriptions issued by general practitioners.
“We don’t know the facts, but it’s a common perception that antibiotics are overprescribed and many people have experienced this,” Ho says. He cites lack of peer pressure as a possible explanation. “In public hospitals, a doctor’s work is observed by colleagues and governed by supervisors, but most doctors in private clinics are solo practitioners, operating in isolation.”
Alex He Jingwei, an expert on health policy and reform at the Hong Kong Institute of Education, says East Asian culture may be partly to blame.
“There’s a misconception that the purpose of visiting a doctor or hospital is to obtain medicine. If patients are denied a prescription, they tend to feel short-changed and, inevitably, this influences doctors’ behaviour.”
Education could help reverse the trend.
“It’s market forces,” Yuen says. “If patients are better informed, and they say they don’t want antibiotics, doctors’ behaviour will change.” Yuen also hopes to dissuade people from buying antibiotics over the counter, without a prescription. “It’s illegal, but we know it goes on.”
Although Hong Kong’s private sector has its shortcomings, “in mainland China the problem is systemic”, He says. “Public hospitals [in China] receive only 10 per cent of their funding from the government, so they make up the 90 per cent shortfall by charging patients for medicines.” Doctors are underpaid and “to top up their nominal salary, they have to draw deeper from patient pockets”.
Fierce competition in the Chinese pharmaceutical industry makes matters worse.
“Companies give doctors generous commissions for every prescription,” He says. “Overprescribing antibiotics is lucrative and easy because they don’t cause immediate adverse side effects for patients.”
He believes China’s National Action Plan signals the government’s good intentions but is not confident it can bring about significant change in the near future.
“The problem,” He says, “is systemic, and deeply locked in.”
Ho is not optimistic, either.
“The crisis is nothing new. International agencies have been sounding the alarm bell for 50 years and there’s no shortage of guidelines and recommendations. The problem is that with the exception of Australia, New Zealand and a few countries in northern Europe, no one has followed the recommendations.”