The story of antibiotics is a cautionary tale of a huge scientific triumph followed by great complacency. Today, antibiotic resistance is a silent, hidden pandemic, with profound consequences for global health. The main causes behind the rise of superbugs are complex and multifaceted. Between 2000 and 2015, there was a startling 65 per cent increase in antibiotic usage, particularly in low- and middle-income countries. This surge has inadvertently given bacteria ample opportunities to develop resistance and become superbugs, which spread seamlessly through humans, animals, and even the environment. And poor access to water, sanitation, and hygiene only exacerbates this situation.

A stark illustration of this menace can be seen among the most vulnerable section of any population – our infants. Infectious diseases remain a leading cause of death for children under five. Globally, over 210,000 infant deaths are annually attributed to drug-resistant septic infections. And when you dig deeper, studies highlight that just one superbug, the antibiotic-resistant Klebsiella pneumoniae, contributes to mortality rates of 10-12 per cent among newborns with sepsis.

In India, more than half the strains of Klebsiella pneumoniae are already resistant to last-line antibiotics, making the situation particularly alarming – infants who pick up this superbug often have no chance.

Moreover, the misuse of antibiotics isn’t limited to hospitals. In the community, unwarranted prescriptions abound. A 2023 study of 59 low- and medium income countries published in the eClinicalMedicine journal found that a staggering three of four children reporting fever and cough were prescribed antibiotics. However, calling antibiotic resistance only a medical issue undersells its magnitude. It’s an overarching public health crisis bridging human, agricultural, and environmental realms.

So, where might solutions lie? One promising avenue is the advent of rapid diagnostic tests. These revolutionary tools have the potential to not only pinpoint the microbial culprit behind infections, but also to indicate its resistance profile within hours. Such precision would empower clinicians to streamline treatments, reducing the reliance on broadspectrum antibiotics.

But other challenges continue to persist. The identification of disease-causing microbes can still take days, making rapid diagnostic tools a luxury in many scenarios, especially in resource-poor settings. The result is that many healthcare providers resort to treatments based on symptoms rather than confirmed diagnosis. Even when physicians are aware of the limitations of antibiotics, the pressures of patient expectations or perceived caution can skew their judgement.

Further, the problem is compounded by the preventative use of antibiotics, often done to mask the lack of sanitation or to ward off potential secondary infections. These prescriptions for antibiotics are inappropriate for treating conditions like viral respiratory tract infections, which account for a significant percentage of antibiotic misuse.

Historically, prescribing antibiotics for a week or longer was common, often due to the need to be safe. Today, despite guidelines recommending shorter treatment periods, many infections like community-acquired pneumonia are still treated for ten days or longer, exposing patients to unnecessary risks.

Combating superbugs requires understanding how resistance develops through interactions among bacteria, their hosts, the environment, and human interventions. What we need to talk about more, however, is the environmental dimension of antimicrobial resistance. Antibiotics don’t magically disappear after they’ve served their purpose in medicine or agriculture. They persist in our waterways and soil, creating environments where only the fittest, most resistant, superbugs thrive. The consequences of our choices today will be suffered by future generations – the very medicines designed to save lives today could be shaping an ecosystem hostile to life in the long term.

The intricate relationship between bacteria and their environments significantly impacts our health and well-being. Far from being isolated entities, bacteria continually swap genes, a process that has the potential to turn harmless strains into undefeatable superbugs. The superbug crisis is further heightened by our planet’s changing climate. As global temperatures rise, so does the speed at which bacteria replicate, perpetuating a cycle where the demand for effective antibiotics surges while their efficacy falls.

Addressing this multidimensional issue demands a holistic approach that incorporates human, animal, and environmental health. We must embrace the idea that our well-being is intrinsically tied to the health of animals and our shared environment.

Every facet of life on Earth, from our health to our food sources and even our ecosystems, is currently being imperilled. Bacteria are adapting to the world as we change it, and we are heading closer to a post-antibiotic era where even the simplest infections are deadly. Confronting this adaptive challenge mandates that we, too, evolve in our response, to protect antibiotics as a shared, societal resource. We must understand that the problem of superbugs isn’t just an issue of health but a deeper socio-economic one. In many countries, packed cities grow even further, and a combination of poor sanitation, low-quality water, and poor hygiene increases the spread of superbugs.

A growing area of concern is the rise in antibiotic resistance within livestock such as chickens, cows, and pigs. Consuming these animals transfers the resistant bacteria into our systems. Yet, animals aren’t solely the cause of such transmissions. Humans, often guilty of antibiotic misuse, can inadvertently transfer these resistant strains back to the animal kingdom. This mutual exchange, which is particularly rampant in environments with subpar hygiene and lax safety measures, only exacerbates the situation.

Poor water and waste management systems, especially in developing nations, worsen the situation. The proximity of waste dumps to residential and farming areas can result in antibiotic-resistant bacterial contamination of water sources and food. Even seemingly inconspicuous entities, like flies, can serve as carriers and spread these bacteria.

Superbugs know no boundaries. Given the ubiquity of international travel and commerce, antibiotic resistance has transcended continents, making it a global concern. Consider the vibrant cattle trade between India and Bangladesh, valued at over US$600 million annually. Much of this trade bypasses official channels, eschewing crucial safety checks. This pattern mirrors the ones in countries like Nigeria, where a sizeable chunk of the poultry trade follows an informal trajectory. Coupled with scant access to veterinarians in some regions, antibiotic misuse runs rampant.

The interplay between poverty, infectious diseases, and antibiotic resistance forms a self-perpetuating cycle. Those in poverty are disproportionately affected by infectious diseases. The contributing factors are many – overcrowded living conditions, insufficient nutrition, lack of access to clean water, and inadequate healthcare. These conditions not only facilitate the spread of infections but also create environments in which diseases flourish.

As infectious diseases take hold, the economic burden they impose can be crushing. The costs associated with medical treatment, coupled with the loss of income during illness, perpetuate poverty. Complicating this issue is the pervasive spread of antibiotic resistance, a dire consequence that emerges from the depths of poverty. In areas where healthcare systems are strained and health education is lacking, antibiotics are often misused, whether through incomplete courses of treatment or unregulated distribution.

The result is a harrowing cycle where the consequences of illness serve to reinforce the impoverished conditions that initially made individuals vulnerable. Breaking this cycle requires more than just medical intervention; it requires improving sanitation and access to healthcare and encouraging responsible antibiotic use along with socioeconomic support.

Addressing this challenge requires customized solutions that resonate with the unique challenges of communities. At a basic level, we should prioritize solutions like improving sanitation and hygiene. The COVID-19 pandemic made people aware of the importance of these solutions in disease prevention, and we must capitalize on this momentum.

Excerpted with permission from When The Drugs Don’t Work: The Hidden Pandemic that Could End Modern Medicine, Anirban Mahapatra., Juggernaut Books.