Antibiotic resistance: a collective problem, badly shared

Last winter I asked for antibiotics for a sore throat, the doctor said no, and on the way out I reread the poster in the waiting room: antibiotics are not automatic. The message targets the patient who asks and the doctor who gives in. It isn’t wrong. It’s just calibrated to the part of the problem that fits inside a surgery, which is very convenient.

Bacteria don’t cheat, they sort

Before any treatment, a bacterial population already contains a few individuals carrying a mutation that makes them insensitive to a molecule. The antibiotic doesn’t create resistance: it kills the sensitive ones and leaves room for the others, which multiply without competition. It’s selection, in the most mechanical sense of the word.

These bacteria also swap fragments of DNA with each other, including between different species. A resistance that appears on a farm can therefore turn up elsewhere, in a bacterium that never met the molecule in question. The pool of resistances is shared, which is why no individual decision really controls it.

The World Health Organization ranks the phenomenon among the main global health threats, with more than a million deaths a year directly attributable to resistant infections. These aren’t exotic diseases: they’re urinary infections, pneumonia, complications after surgery.

Where the molecules actually go

A considerable share of the antibiotics produced worldwide never ends up in sick humans. It goes into farming, where whole herds are treated preventively because the density of animals makes infection likely. Europe has tightened the rules on growth use, other markets much less so, and bacteria have never respected customs borders.

There is also the end of the chain nobody talks about: manufacturing. Active ingredients are produced in a few plants concentrated on a small number of sites, and poorly treated effluents release molecules into the rivers around those sites. A watercourse dosed with antibiotics is a machine for selecting resistance, continuously, with no patient having forgotten to finish a course.

The economic problem behind the biological one

A new antibiotic is the worst product imaginable for a pharmaceutical company. It costs as much to develop as any other drug, it’s taken for a week rather than for life, and if it works, it gets kept in reserve so it doesn’t lose its effectiveness. In other words, the health success consists in not selling it. The big groups have therefore largely left this area for chronic diseases, and several of the rare companies that brought a new antibiotic to market went bankrupt soon after.

The result is a shortage of new molecules facing resistances that keep accumulating. Public and philanthropic funds now finance part of this research, which amounts to socialising development whose production will remain private.

The poster in the waiting room shows no farm, no factory effluent, no patent. It shows a patient, a doctor, and a course to finish.