How do we solve this quintessentially wicked problem of public health and medicine?

Associate Professor Hsu Li Yang, Former Clinical Director, NCID

The term ‘anti-microbial resistance’ is most commonly used in reference to bacterial pathogens that cause nosocomial infections. But because of their intrinsic ability to adapt and evolve, all microbes can develop resistance to the drugs used to target them. Antimicrobial resistance has also become an escalating problem in other microbes that cause human and veterinary disease, particularly in the case of tuberculosis and malaria, where it threatens to roll back the successes of past decades.

The causes of antimicrobial resistance have generally been reduced to a single axiom -antibiotic abuse and overuse - and the problem is exacerbated by the ease of human travel and globalisation (facilitating spread of resistance), as well as the drying up of the antibiotic pipeline (leading to a dearth of new drugs). Such simplifications certainly help with regards to conceptualising and understanding the problem, but fail to capture its complexity.

Solutions based on these reduced parameters of antimicrobial resistance will still be very useful, but will have less of an impact or temporal durability than anticipated. Two examples may serve to illustrate this:

• The Netherlands is regarded as a model country with regards to controlling Methicillin-resistant Staphylococcusaureus (MRSA) in her hospitals¹. Yet the Dutch were blindsided by livestock-associated MRSA, with a rising incidence of infections occurring in humans exposed to animal husbandry².
• A sizeable number of new anti-MRSA drugs are now available, easing the concerns of those who fear that MRSA might become untreatable. Yet these drugs are expensive, and access to them remains problematic for those without the means to pay.

There is now greater awareness than before on the issue of antimicrobial resistance, and not just by those in medical- or public health-related fields. The 2013 Global Risks Report of the World Economic Forum specially highlighted the risk of antibiotic resistance to health, social and economic systems³. The UK government put forward a 5-year antimicrobial resistance strategy in 2013, matched in 2014 by the White House with its national strategy on combating antibiotic-resistant bacteria.

Nonetheless, there remains no single solution or defined roadmap for the control of antimicrobial resistance. The issues associated with this ‘wicked problem’ will need to be clearly communicated to the community at large, with local social, economic and cultural roadblocks addressed in addition to developing new diagnostic tests and antimicrobial agents⁴. In this respect, our reticence in publicly discussing or even highlighting the issue of antimicrobial resistance in our hospitals and community does more harm than good.

Denmark’s “One Health” approach offers a glimmer of hope – its remarkably detailed DANMAP report showed a steep fall in extended-spectrum betalactamase-producing Escherichia coli in broiler meat since 2011, with low rates of sentinel antibiotic-resistant bacteria in both humans and local meat⁵. But it will take most countries – even Singapore - decades, if at all, to achieve a comparable standard of a One Health approach.