The Next Pandemic

Photo by Adam Nieścioruk on Unsplash ABSTRACT Antibiotics are useful to stave off infection, though their misuse can be detrimental creating drug-resistant infections. It is essential that we closely examine the leading causes of antibiotic resistance and consider serious clinical ethical ramifications around issue. This paper will aim achieve these goals, as well propose practical solutions directed towards combating this looming crisis. INTRODUCTION As drug companies race develop vaccines treatments in response COVID-19 pandemic, other impending public health threats may easily forgotten tucked away for another day. Experts warning “the same governmental inaction helped foster rapid, worldwide spread coronavirus spur an even deadlier epidemic infection…”[1] Dr. Jeffrey R. Strich, a researcher at National Institutes Health Clinical Center remarked, “If there’s anything pandemic has taught world, it being prepared more cost-effective long run.”[2] Antibiotic resistant infections cause estimated 700,000 annual deaths globally.[3] According Centers Disease Control, United States alone, sicken 2.8 million people annually responsible least 35,000 each year.[4] The Nations suggested that, if problem not soon addressed, could kill up 10 2050.[5] genesis complex multifaceted. Successfully require global response. resistance. also devote discussion use misuse. Lastly, measures countries, such US, should taking now help stem ever-evolving emergency. I. develops when bacteria exposed antibiotics, propelled forces evolutionary selection, mutate over time adapt antibiotics.[6] process greatly accelerated overexposed antibiotics.[7] Overexposure occurs two primary ways – first through overuse/misuse antibiotics humans second misuse/overuse animals. A. In studies, treatment decisions involving including whether antibiotic, which use, appropriate duration incorrect 30 percent 50 cases.[8] overprescribed cases where they truly needed, or wrong type dosage prescribed. These issues contribute resistance.[9] many cases, faulty determinations attributed lack available microbial testing. Consequently, healthcare providers unable properly identify classify bacteria, thus impairing ability make clinically sound decisions. one US study hospitalized patients suffering from community acquired pneumonia, example, pathogen was identified only 7.6% cases.[10] There existing technology, specifically polymerase chain reaction (PCR) semiquantitative PCR, accurately identifies pathogens approximately 89 cases.[11] However, technology widely used. When do testing, often rely upon culture rapid delay proper assessments.[12] result, substitute inappropriate interim. Another among stop regimens prematurely, thereby allowing harmless fully eradicated due abbreviated treatment, acquire then genetically transferred dangerous bacteria.[13] unfortunate, frequent occurrence developing countries without prescription accessed unregulated supply chains.[14] Developing nations frequently suffer dearth standard guidelines, further precipitates overprescribing.[15] B. animals Approximately half world’s consumption agricultural purposes.[16] 20 sales intended human while remaining 80 livestock.[17] Despite gross disparity, publications discussing address role plays.[18] contributes Farmers agribusinesses distribute feed water, healthy animal populations non-therapeutic purposes -- growth promotion disease prevention.[19] need prevention arises animals’ living quarters cramped prone disease.[20] Low concentrations have routinely been observed gastrointestinal tracts livestock.[21] presence sub-therapeutic levels drugs fosters genes guts.[22] developed used sources food, both passed along food supply, contaminating milk, meat, eggs.[23] Because those critically important applications, destroy prospect effective options humans.[24] Environmental Working Group, supermarket meat poultry contain extremely high bacteria. Specifically, ground turkey found 79 pork 71 percent, beef 62 chicken 36 percent.[25] While killed with heat (from cooking, instance), DNA accompanies always eradicated. who consume it, conferring otherwise benign digestive systems.[26] Resistant contained waste enter environment pollutants, settling ground, air, water systems.[27] increases transmissibility and, ultimately, person acquires infection and/or passes others.[28] unintended adverse consequence foods like eggs residues.[29] Since 90 excreted animal’s waste, pollute groundwater.[30] Unnecessarily prolonged exposure risk acquiring bacterial infection. constant effects, ranging hypersensitivity carcinogenic effects.[31] II. Ethical considerations obligations stakeholders Tackling created sector First, respect humans, there needs vastly scaled-up pathogenic ensure made empirical data, rather than exercise supposition. Increased testing would lead reduction unnecessary prescriptions scripts antibiotic. PCR available, until developed. At most basic level, physicians seek out practices hospitals. Third-party payors poised approve costs associated tests, since expedite improvements patients’ health, resulting overall cost savings. pharmaceutical industry accurate, technology. Rapid abbreviate immediate illnesses, because knowledge provided quickly determine diagnoses. allow them immediately prescribe correct antibiotics. Finally, regulations access must implement sufficient restrictions. Addressing level imperative. Like COVID-19, pragmatic perspective, create prevent spreading.[32] Some ethicists argued good, overuse result sort “tragedy commons.”[33] order equitable distribution all patients, society disincentives use. One proposal involves taxing “minor self-limiting” infections.[34] punished following physicians’ recommendations. Things schemes unjustifiably interfere doctor-patient relationship consequences patients. Others asserted owe duty care present future Pursuant argument, ethically justified increasing harm “small” amount denying if, doing so, decreasing significant patients.[35] per Hippocratic Oath, obligation foremost, current includes act good patient (with beneficence) befalling (non-maleficence). Nowhere Oath does say “a little” acceptable. Failing provide warranted “preserve” violation bioethical patient. best interests avoid own superfluous case-by-case basis, relying evidence, impermissible imperative breach patient’s right autonomy believes physician acting strictly his her interest relies physician’s recommendations belief. From become “large” harm, depending A misjudge involved depriving increased morbidity mortality imply never proposing reasonable waiting period before prescribing illness self-limiting begins improve its own. again, decision driven criteria addition, proposals disincentivize dangerous. Although prudence necessary, dissuaded when, judgements, necessary. Without seemingly turn deadly. Untreated bronchitis rapidly progress pneumonia. strep throat heart damage. lingering urinary tract induce sepsis.[1] III. Combating scholar aptly observed, “[t]he debate ethics [antimicrobial resistance] heavily disproportionately focused humans…this focus reflects traditional discourse medical ethics…”[36] seems relevant note seeming irrationality advocating withholding failing widespread, indiscriminate, sector. bottom line important, cannot overshadow substantial played several key under take action. FDA rule banning took small step 2017 limiting finally restricted farms using medically agents animals.[37] move, however, described grossly insufficient. For one, still promotion, “preventive health” “times stress,” clearly defines.[38] Therefore, newly imposed restriction easy circumvent. Farms simply purchase measure purposes.[39] To complicate matters further, labels any parameters meaning indefinitely throughout lives.[40] promoting “growth” ancillary benefit encouraging unbridled use.[41] next elimination crowded, inhumane conditions administer “preventive” established “[a]ntibiotics subtherapeutic promote crowded raised in.”[42] livestock compared hospitals “where everyone given lie unchanged beds, hygiene nonexistent, re-infections rife, thrown window, visitors leave will.”[43] Eliminating reduce preventive establish surveillance enforcement mechanism compliance addressing conditions. Surprisingly, notwithstanding documented link between lacks means monitoring farms’ uses assess possible sale farms.[44] chemical manufacture required information FDA.[45] reports indicated sold purposes, contends discern actual numbers. time, failed rules alternative use.[46] New York Times investigation revealed, investigators regarding farm’s practices.[47] constructs roadblocks so government’s farms, how animals, hindered.[48] Further complicating matter conflicts executives hold positions advisory committees government agencies, Department Agriculture (USDA).[49] USDA system studies sector.[50] expert recent Washington Post article opined, USDA’s oversight laissez-faire. They test fraction can’t taken seriously…and rotate for, afford them. just don’t funds it. We raise 9 billion hundreds cattle, thousands.”[51] self-reporting, voluntary questionnaires,[52] calls into question completeness veracity data. addition government, reign imprudent 2007, legislation introduced manufacturers phase animals.[53] industries, major opposed legislation.[54] incumbent support fight against creates products, great deal some argue tasked overseeing poor products. But encourage refrain touting “ancillary benefits” “growth promotion,” encourages injudicious illegal Consumers pay price three industries’ actions. People eating products no opportunity consent choose antibiotic-free dairy, residues, aware risks. bear burden industries profit. designated “organic,” producers allege were production tend significantly expensive organic. lower socio-economic brackets forced buy higher healthier principle distributive justice. Industry work find innovative playing field safe consumers, regardless economic disposition. Simply put, consumer worry about supply. IV. Creating incentives development chipping approach, win war. Since, mitigation causal factors, inevitable level. crisis tail-end. ensuring occur, this, new classes potential treat landscape research barren one. Pharmaceutical largely bailed area biotechnology startups going bankrupt pursuing venture. piece noted, “[i]n 1980s, 18 antibiotics; today three.”[55] prefer chronic diseases, term, continuous profits.[56] Antibiotics, hand, prescribed short-term basis acute limits inherent capacity generate profits.[57] reluctant recouping investments.[58] Bioethicist Ezekiel Emanuel government-sponsored prize money approved stating prestige, bragging rights renewed sense mission alone investment worthwhile.”[59] Twenty pooling capital fund smaller, dedicated collaboration World Organization. recently announced $1 biotech start-ups. pool, called AMR Action Fund, but “amid collapsing industry.” go 24 already working promising drugs.[60] foregoing approaches laudable, sustainable. Each $2.6 develop.[61] establishment non-profit organizations approach. published England Journal Medicine 2019 explained, nonprofits “don’t face pressure revenue drive shareholder value venture capitalist investors demand very rates return short periods. less increase prices.”[62] nonprofits, TB Alliance Medicines Malaria Venture, proven development.[63] Ultimately, challenge non-profits enough funds. Perhaps funds, coupled funding, toward non-profits’ efforts. CONCLUSION growing concern globe demands our collective, attention. Organization seem slow-moving, abstract pandemic.[64]Antibiotic attention solutions. warned, “…one day, us…will world longer something terrify everyone.”[65] [note 1] aside, taxation discourage startups. Already strapped profits discussed below, taxes worsen situation. [1] Jacobs, “Doctors Heavily Overprescribed Early Pandemic.” Times. (June 4, 2020). [2] [3] “No Time Wait. Securing Future Drug Infections. Report Secretary General Nations.” (April 2019). Available : https://www.who.int/antimicrobial-resistance/interagency-coordination-group/IACG_final_summary_EN.pdf?ua=1 [4] “About Resistance.” Control. at: https://www.cdc.gov/drugresistance/about.html [5] [6] Munthe, C. et. al. “Health-related Research Ethics Social Value: Resistance Intervention Pragmatic Risks.” Bioethics. 33:335-342 (2019). [7] “Antibiotic Key Facts.” https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance [8] Ventola, C.L. “The Crisis.” Pharmacy Therapeutics. 40:4:277-283 (2015). [9] [10] [11] [12] Parsonage, B., et “Control Antimicrobial Requires Approach.” Frontiers Microbiology. 8:2124 (November 2, 2017). [13] Chin, T. Affairs. (May 21, 2015). [14] Manyi-Loh, Its Consequential Sources: Potential Public Implications.” Molecules. 23:795 (2018). [15] [16] Littmann, J. Significance Ethics. 8:3:209-224 [17] 2015); He, Y. waste: occurrence, dissemination, treatment.” NPJ Clean Water. 3:4 (2020). [18] [19] [20] [21] [22] (2020); [23] [24] “Reports Offer Valuable Information Stewardship U.S. Agriculture.” Pew Charitable Trusts. (September 12, https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2019/09/reports-offer-valuable-information-on-antibiotic-stewardship-in-us-agriculture [25] Supermarket Meat Still Superbugged, Federal Data Show. Group. 28, 2018). https://www.ewg.org/research/superbugs/ [26] Verraes, “Antimicrobial Food Chain: Review.” International Health. 10:2643-2669 (2013). [27] [28] [29] [30] [31] [32] perspective entail assisting building infrastructure capabilities vast nature topic, challenges, warrants separate discussion. [33] [34] Giubilini, tragedy commons: An argument tax humans.” 33:776-784 [35] Leibovici, L. “Ethical dilemmas Chemotherapy. 67:12-16 (2012); [36] [37] “Antibiotic/Antibiotic Animals.” https://www.cdc.gov/drugresistance/food.html; McKenna, M. “After Years Debate, Finally Curtails Use Livestock.” Newsweek. January 2017. [38] Guidance Industry, #213. Administration. https://www.fda.gov/media/83488/download; Must Ensure That All Animal Have Defined Durations use.” https://www.pewtrusts.org/en/research-and-analysis/articles/2019/04/01/fda-must-ensure-that-all-animal-antibiotics-have-defined-durations-of-use; [39] [40]“FDA [41] Hakim, D., Richtel, Warning ‘Pig Zero’: Drugmaker’s Push Sell More Antibiotics.” 7, [42] Duckenfield, Due Modern Agricultural Practices: Perspective.” 26:333-350 [43] [44] “Questions Answers: Summary Antimicrobials Sold Distributed Food-Producing https://www.fda.gov/industry/animal-drug-user-fee-act-adufa/questions-and-answers-summary-report-antimicrobials-sold-or-distributed-use-food-producing-animals; “Tainted Pork, Ill Investigation Thwarted.” August 2019. [45] website. https://www.fda.gov/industry/animal-drug-user-fee-act-adufa/questions-and-answers-summary-report-antimicrobials-sold-or-distributed-use-food-producing-animals [46] [47] [48] [49] [50] Website. Overview.” https://www.usda.gov/topics/animals/one-health/antimicrobial-resistance-overview-amr# [51] Reiley, “Some ‘raised antibiotics’ tests positive study.” Post. April 2022. [52] Plan.” https://www.usda.gov/sites/default/files/documents/usda-antimicrobial-resistance-action-plan.pdf; USDA. Feedlots, 2017” https://www.aphis.usda.gov/animal_health/nahms/amr/downloads/amu-feedlots_1.pdf [53] [54] [55] “Crisis Looms Makers Go Bankrupt.” (December 26, [56] [57] [58] [59] Emanuel, E. “How Develop (February 24, [60] “Drug Giants Create Fund Bolster Struggling Start-Ups.” (July 9, [61] [62] Nielsen, T.B. “Sustainable Discovery Development Is Nonprofit Approach Future?” Medicine. 381:6:503-505 [63] [64] 2020)(citing Peter Beyer, Senior Adviser Organization). [65] (Quoting Everly Macario, Expert University Chicago Medicine).