A Global Tour of Drug Resistance

January 28, 2010

By Rachel Nugent

Katherine Douglas contributed to this blog.

Two award-winning journalists spent the better part of 2009 taking a global tour of drug resistance. The sights they found were astonishing – and terrifying. I spoke to one of them, Margie Mason, shortly after their five-part series entitled “When Drugs Stop Working: An Emerging Threat to Global Public Health” ran in newspapers around the world—unfortunately, in my view—during the week between Christmas and New Year. CGD has been tracking Margie’s journey and providing background information to her since she set out. Margie explained,

I was surprised by some of the things we found: I had no idea antibiotics were sprayed on fruit trees, and injected into palm trees. We also found there are 700 antibacterial or antimicrobial products on the market. Do you really need antimicrobial slippers and chopsticks? 

You’ve got to admire Margie, a recent recipient of a Nieman Journalism Fellowship at Harvard University, and her Pulitzer-prize winning co-author, Martha Mendoza. This topic doesn’t exactly lend itself to the 3 paragraphs, 1 column format of USA Today. It’s complex, it’s hard to find the victims since many of them don’t know they have a drug-resistant disease, and there’s no smoking gun. “Drug resistance is not immediate”, explains Margie. “It’s a slow, silent moving problem with many different aspects…it’s a truly global problem, and one that everyone is contributing to.” She continued, 

Drug resistance was a real challenge to report on. It’s such a big issue and we tried to simplify and make it interesting to read about. There have been piecemeal stories but no-one has pulled it together in a comprehensive package. Our task was how to find things that haven’t been reported.

Our star gumshoes succeeded at that. In their first article—a breaking story that had never been made public—Mason and Mendoza reveal the first case of highly drug-resistant tuberculosis (coined XXDR-TB) in the U.S. They describe 19-year old Oswaldo Juarez’s struggle with the highly contagious and aggressive disease during his visit to Florida from Peru. Although XXDR-TB had never before been seen in the U.S., Dr. David Ashkin, one of the nation’s leading experts on tuberculosis and the medical director at AG Holley, the quarantine hospital where Juarez lived for a year and a half, explains that the case of Mr. Juarez “Really is the future. XXDR tuberculosis is so rare that only a handful of other people in the world are thought to have had it. This is the new class people are not talking about.” 

The capacity for TB to evolve into more aggressive and resilient strains is, in the words of Dr. Masae Kawamura, who heads the Francis J. Curry National Tuberculosis Center in San Francisco, “a time bomb…a man-made problem that is costly, deadly, debilitating, and the biggest threat to our current TB control strategies.” 

Margie’s take on it? 

The story of the kid in Florida was an incredible tale from a journalistic standpoint. We were trying to find XDR-TB in the U.S. There are a handful of TB centers across the country. AG Holley [a former TB sanitarium in West Palm Beach, Florida] is like a museum with all the old equipment. There are dark corridors, now without patients lining the walls, but where you can close your eyes and imagine yourself in another century. There are incredible patients there from all over the world. We met an Indian woman who came to the AG Holley with resistant TB and was separated from her newborn for eight months. 

The two reporters’ drug resistance world tour tells of similarly heart-stopping sights elsewhere with the freshness that comes from seeing the problem for the first time. Frankly, it’s a welcome change from the scientific journals that produce almost all of the available knowledge about resistance. The journalists’ labor poured out over five days in late December, starting with Oswaldo’s story.

Day Two: The first evidence of resistance to artemisinin combination drugs for malaria in Thailand – the same corner of the world where resistance to earlier malaria drugs began, and then spread worldwide. 

      · Day Three: The use of antibiotics in agricultural practices – amounting to 245 million tons of antibiotics consumed by animals in the U.S. alone.

      · Day Four: The emergence of drug-resistance strains of HIV in South Africa – new and more resilient strains of HIV are being detected in roughly 5 percent of new patients in Africa, with higher resistance rates found in the U.S. and Europe. 

      · Day Five: The link between reduced antibiotic use in hospitals and better health results in Norway – while more than 65,000 people die of hospital-acquired infections annually in the U.S. alone. 

Throughout the series, Margie Mason and Martha Mendoza compile personal stories, statistics and expert opinion to describe the dangerous capacity for medicine use to go wrong and create highly-resistant strains of infectious diseases. They conclude, “Forty years ago, the world thought that it had conquered TB and any number of other diseases through the new wonder drugs: antibiotics. Today, all the leading killer infectious diseases on the planet are mutating at an alarming rate, hitchhiking their way in and out of countries.”

Did they arrive at this conclusion because their reporter instincts lead them to invent a crisis? No, these conclusions come straight from sober scientists. Dr. Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, and a veteran of the fight against resistant TB in the U.S. asserted, “If we’re not careful with antibiotics and programs to administer them, we’re going to be in a post antibiotic era”. Margie and Martha also quote Norway’s MRSA Control Director, Dr. Petter Elstrom, who is apprehensive about the multi-drug resistant strain of Staphylococcus aureus—commonly dubbed MRSA. “So far we’ve managed to contain it, but if we lose this, it will be a huge problem. To be very depressing about it, we might in some years be in a situation where MRSA is so endemic that we have to stop doing advanced surgeries, things like organ transplants, if we can't prevent infections. In the worst case scenario we are back to 1913, before we had antibiotics."

Margie’s first-hand assessment is down-to-earth.

These strains are even scarier in the developing world. They can’t get treated. You can talk about these things and make plans about prevention and treatment. But when you see the setting you realize how challenging it is to make things work. These people are moving around all the time, they are poor.

Margie explained also that she was overwhelmed by the sheer scale of the problem.

I’ve been having dreams about drug resistance, waking up thinking about it. We’ve read books, interviewed hundreds of people. There’s just so much. We tried to hit on as many of the big issues as we could, but there are many others. We didn’t get into advertising or talk much about all the incentives paid to doctors to prescribe drugs. I’ve heard all kinds of anecdotes about what people get for prescribing drugs. We’re very quick to blame poor countries but in this case it’s a truly global problem, and one that everyone is contributing to. 

There are, however, some glimmers of hope. In her interview with me, Margie noted the example of a Japanese doctor, who, after realizing that the nation’s seemingly ultra-modern, sterile facilities revealed MRSA levels that were among the highest in the world, changed his practices to reduce the frequent use and dissemination of antibiotics—and got positive results. Margie and Martha finish the series with a story about hospitals using amplified precautions (including universal screening programs) to reduce hospital-acquired infections in Pittsburgh. “There are ways to control this; it’s not a doomsday scenario,” Margie reports, adding that “there is more awareness now than a long time ago.” 

Awareness, such as that generated by the AP series and similar articles, will be crucial in stemming the spread of once curable drug-resistant diseases across the world. To learn more, read the consultation draft report of the CGD Working Group on Drug Resistance. This is a manageable problem if only we all are willing to take the world tour with Margie and Martha.