Every year more people die from microbes that have evolved to evade modern medicine, than do from malaria and AIDS combined. By the year 2050, antimicrobial resistance could overtake cancer as the leading cause of death. The post-antibiotic apocalypse is already here, and we need to learn to live with it, argue Lorenzo Servitje and Clare Chandler.

You have been exposed to antimicrobial resistance. You have likely seen news stories about “the silent pandemic” and warnings about “superbugs.” A doctor may have hesitated to prescribe you an antibiotic or a pharmacist counselled you to take your entire course of antibiotics, even if you felt better. For those unfortunate enough to develop an infection that is drug resistant, this can mean a hunt for a next-line antibiotic and if that fails, a long period of recovery as the body uses its own defences to fight the infection. Sadly, for many, recovery becomes impossible. Patients, families and health care workers become reminded of the miraculous quick-fix that antimicrobial medicines are, and how we have come to take them for granted.

Understandably, a future without antibiotics looms as a dire spectre. The language used to describe such a future is often apocalyptic in nature, much like in the case of climate change. But like climate change, the warnings are not about a distant future that we’re trying to prevent. Antimicrobial resistance is already here.

Unopened Penicillin Ampoule (1946), first discovered in 1928, and later synthesized
into a therapeutic at scale in 1945.

 

Antimicrobial resistance (AMR) occurs when microbes evolve mechanisms that allow them to neutralize or evade the medicines we have developed to treat the infections they cause. This phenomenon can occur in all forms of microbial life: viruses, parasites, fungi, and bacteria. While AMR occurs in nature, over 80 years of widescale use of antimicrobials has created concentrations orders of magnitude beyond what pre-twentieth-century microbes had encountered. Consider this evolutionary pressure, along with the ability of microbes to exchange genes with each other capaciously. Compound that with the expansive and dynamic reservoir that human travel, trade, industry, and infrastructure have created in the environment--and the extent of AMR becomes challenging to grasp. Though the scale of the risk and its different drivers and mediators can be hard to conceptualize, the human cost is clear--but not necessarily made visible.

Despite the complexity and extent of the problem, time is still of the essence. This is not a hypothetical future or concern for “what’s coming next”; antimicrobial resistance is already here--we are in trouble now.

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The O’Neil report in 2016 estimated that by 2050, ten million people could die each year, potentially eclipsing cancer as the leading cause of death.

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In 2019, 1.27 million deaths worldwide were directly attributed to resistant bacterial infections, according to a recent study in the Lancet. As a point of familiar reference, the number of deaths caused by AMR annually is nearly 50% of the 3 million people who died attributed to COVID-19 worldwide in 2020; that’s nearly equivalent to the annual mortality of HIV/AIDS and malaria combined.

It is critical to examine the trajectory of the mortality from AMR, both in time and space. The burden is growing: The O’Neil report in 2016 estimated that by 2050, ten million people could die each year, potentially eclipsing cancer as the leading cause of death. This pervasively cited figure alerts us to the need for urgent action to prevent this future threat. One and a quarter million people dying each year is already pretty dire, but ten million is on a different scale. Equally important is that this mortality burden is shouldered unevenly. According to the Lancet study, Western sub-Saharan Africa had the highest AMR burden: 27.3 deaths per 100,000 attributable to AMR (125,000 lives lost of the global 1.27 million, or approximately 10% of deaths globally). This figure however doesn’t tell the whole story. In the supplementary file of the Lancet study, the breakdown of AMR burden figures shows that the Western Sub-Saharan region also had one of the highest death rates from non-AMR infections (93.3% of deaths from all infectious diease). Here, tackling infection prevention and increased access to antibiotics will therefore likely have far more of an impact on overall deaths than focussing on over- or mis-use of antibiotics.

Beyond regional geography, the burden is also likely to be shouldered quite differently according to the kinds of housing and settings people live in, their gender, their social status, access to healthcare and comorbidities. The data on the sub-groups who are most affected is strikingly limited. Perhaps it has been more compelling for AMR advocates to aggregate national and regional data to project AMR as a sentinel threat. But to do so obscures those whose lives constitute those numbers.

These people and their deaths might have been counted, but, how can they also be made to count, to make them matter? Our future will inevitably continue to involve resistant microbes. We can make choices that will minimise the burden of drug resistant infections. To do so requires us to attend to those most affected and to set a track for this burden to be reduced -- be it through infection control, better access to medicines, and careful planning for non-pharmacological interventions - today.

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The often-cited ‘post-antibiotic apocalypse’, a future dystopia that jettisons medical modernity and send us back to the pre-antibiotic era, might be counterproductive.

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The AMR crisis is often compared with climate change - antibiotics and carbon as diminishing resources that require action now to prevent disaster tomorrow. However, our future with AMR is often imagined as avertable, with mitigation efforts including new antibiotics and better use of existing antibiotics. But perhaps a framing of ‘adaptation’ is also needed - to consider how we can live with these microbes. What has stopped AMR from being understood in these terms - less about developing next-generation therapeutics and more so building and improving essential public health and healthcare infrastructure? The rhetorical and figurative framings used to galvanize concern about AMR provide insights into our imagination about what is, and is not, possible.

Because antibiotics have been serving as "quick fixes" for care, hygiene, inequality, and fractured healthcare systems, simply controlling their "mis"- or "overuse" in low-to-middle-income countries can detract attention from building sustainable access to care and public health infrastructure.

 

The often-cited ‘post-antibiotic apocalypse’, a future dystopia that jettisons medical modernity and send us back to the pre-antibiotic era, might be counterproductive. Not unlike responses to climate change over the past two decades, however, research has shown that the dystopian cataclysmic framing of AMR can make people develop “apocalypse fatigue,” fatalistic attitudes, or even disbelief.

It is without question that the post-antibiotic era is here. We cannot simply rely on antimicrobials in the way we had in the 20th century and assume they will always be available when we need them. We cannot assume there will be one or more miracle drugs--moonshot magic bullets--that will reset nearly a century of evolutionary pressure. So where does that leave us? Perhaps, it means not thinking of ‘apocalypse’ as a future end, but rather a present revelation.

Our only option is to “stay with the trouble,” as feminist science and technology scholar Donna Haraway might put it. What this entails in our case is embracing both the post (what comes after) and the apocalyptic (in the sense of a revelation or uncovering) in the post-antibiotic apocalypse, rather than resigning to cataclysmic fatalism or technological utopianism. Embracing the post demands we acknowledge we are already living in a “new normal,” not a golden age of medicine---when a dozen antibiotic classes were to be discovered and deployed every decade. Attending to the apocalyptic demands of us not to see what might come in the future but instead look closely at what has been revealed about the trouble we are already living with, how we got here, and how we might live with it in the most sustainable and equitable ways.

Students at Lehigh University learn about bacteriology and resistance at the citizen-science community event, Microbes Among Us, during National Public Health Week (USA).

 

In actionable terms, staying with the AMR trouble and attending to the post-antibiotic apocalypse charges us to reimagine our relationships with microbial life and incorporate drug-resistant microbes as a permanent feature of future life. Also, rather than leaving the public fearful for the future, the public need to be engaged in creating solutions beyond mere pleas to stop the over-use of antibiotics. Students have already been engaged in efforts to make microbes visible for example, the  Microbes Among Us Initiative, and in helping find solutions in their own backyards in the Tiny Earth Project. The use of video games to teach both the past and present of AMR has proved an innovative way of showing rather telling members of the public, especially children, the very logic that brought about the world we live in. AMR is a challenge that can be met collaboratively, and by fostering sustainable ways of thinking and living--staying with the trouble today and reducing the burden tomorrow.