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Hello, this is the Global News Podcast from the BBC World Service.
I'm Oliver Conway with your weekly bonus from The Global Story, which brings you a single story with depth and insight from the BBC's best journalists.
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Here's my colleague, Johnny Diamond.
They have saved countless lives and improved tens, maybe hundreds of millions more.
Antimicrobial drugs have transformed the health of humanity.
Some of the greatest advances in those drugs' development have been forged in wartime.
But now those same wars threaten the progress that's been made.
The Russian invasion of Ukraine has led to the emergence of bacteria that are severely resistant to multiple antibiotics.
A new dark age of drug resistance looms as antimicrobial drugs are prescribed in massive quantities on the battlefield and to civilian casualties.
Today, the story of humanity's triumph over disease and how that is threatened by the wars we fight.
With me today is Dominic Hughes, our global health correspondent.
Hello, Johnny. How are you?
It's just lovely to have you on the show.
Thank you very much indeed.
We are talking, of course about antimicrobial resistance can we start with where we were before we had drugs like these where we were I guess for civilians but also where we were in wartime yeah so before antimicrobials were really discovered life was essentially precarious even a relatively minor infection could prove
fatal so people say a paper cut could have killed to anything that could lead to an infection.
So any kind of surgery, giving birth, deaths of mothers and babies were really commonplace and treatments were pretty medieval.
Bloodletting was a treatment for pneumonia.
Fresh air was the main treatment for tuberculosis and for hundreds of years mercury compounds were used to treat syphilis but also that came along with terrible side effects.
And of course, on the field of battle, any little cut could be really dangerous because battlefields are full of dirt, other people's bloods, bits of hot metal flying around.
There were a lot of serious injuries and from that, deadly infections.
OK, so then along come antimicrobials.
Now, I think a fair number of people will probably be thinking, hang on, antimicrobial antibiotics, are they one and the same thing?
they're slightly different so an antimicrobial is an agent that kills microorganisms or it stops them from growing in the first place so antimicrobial medicines can be grouped according to the different microorganisms they act against so for example antibiotics as you mentioned are used against bacteria antifungals
are used against fungal infections and they can include things like like disinfectants, which are used on surfaces, or antiseptics, which are used on living tissue, for example, during surgery.
And then, of course, antibiotics, which destroy microorganisms in the body.
So antibiotics are a subset of a broader group of antimicrobials.
Exactly that, yeah.
And what about the discovery of antimicrobials and the people that made these, I guess, revolutionary discoveries?
Yeah. So look, there's a really ancient history to the use of antimicrobials.
The ancient Egyptians and the Greeks, they used moulds to treat infection more than 2 ,000 years ago.
But in the 19th century, Louis Pasteur and Jean -Francois Joubert noticed what they described as antagonism between bacteria.
In other words, one type of bacteria stopped the action or the effect of another.
Joseph Lister then used their work and he developed this into the sterilisation of surgical tools and treating wounds, which, of course, had a massive impact on survival rates during surgery.
But then the crucial breakthrough was in 1928.
Alexander Fleming...
I was studying the appearance of staphylococcal colonists.
Staphylococcus is the mycob that gives us boils and carbuncles.
He came back from a holiday to his lab at St Mary's Hospital in London and he found mould that was growing on a petri dish that seemed to be preventing the bacteria that was around it from growing.
They extracted it and purified it and pre -injected into animals and human beings.
This mould produced pretty much a self -defence chemical that could kill the bacteria and he named that substance penicillin.
Penicillin, which is probably what most people, if they think about antibiotics, they think about penicillin as the sort of great father of antibiotics.
You said that happens between the First and the Second World War.
Presumably, it's the Second World War that means you have a massive take up, in particular on the battlefield.
Yeah, it took actually almost 20 years to develop Fleming's discovery into a useful drug.
It's an extremely tricky process to get penicillin made on an industrial scale.
And in fact, it wasn't until about 1942, in the middle of the Second World War, that production of penicillin really took off.
And that happened in the United States.
Industrial monument to the miracle drug.
Mass production penicillin plant at Terre Haute, Indiana.
But very quickly, by 1943, the US had sufficient penicillin stocks to satisfy the demands of both its own armed forces and their allies.
For battle casualties with pneumonia, meningitis, gas gangrene and other wound infections.
It's estimated, right, that penicillin reduced the mortality rate from bacterial infections among wounded soldiers by 15 % and it completely transformed the landscape.
It prevented, for example, many amputations.
It sped up recovery times.
And then after the war in 1946, penicillin became available for the first time in the UK, for example, for public use.
And then there was just this huge growth in discoveries of new types of antibiotics that lasted right up until the 1970s.
And people often refer to that as the golden age of discovery.
How much have we relied on antimicrobials since then?
Well, antibiotics are used to treat or prevent a really big range of bacterial infections.
So things as varied as acne, the sexually transmitted infection chlamydia, kidney infections, pneumonia, but also they're sometimes given as a precaution to prevent rather than treat an infection.
So if you're having an operation or you have a bite or a wound that could get infected or if you have a health problem that means you're at a higher risk of infection, something like having your spleen removed or you're having chemotherapy treatment for cancer, all of those will involve the administration of some
kind of antibiotic.
It sounds like they are very common, both in civilian life and in military life.
Yeah, they really are.
I mean, to give you an idea of the sort of sense of scale, global antibiotic consumption rates since they were introduced have just gone through the roof.
One study in 2021 found that use had increased by nearly 50 % in the last two decades.
It's a bit tricky this, but consumption is measured in what's called defined daily doses per 100 ,000 population per day.
So in other words, it's the proportion of people who are getting antibiotics on any single day on each single day in that year in any given country.
So between 2000 and 2018, that figure has gone from 9 .8 to 14 .3.
Wow. And most of that, yeah, really significant increase.
Most of that increase, interestingly, has been driven by a huge uptake in use in low and middle income countries.
But high income countries have remained also extremely high, but stable.
So you can see the growth now has just really spread right around the globe.
Tom, since I was a kid, there has been talk of in particular antibiotic resistance of all of us becoming resistant or the threat of resistance of no longer being touched properly by antibiotics.
Can you just explain how the resistance builds and how we understand the pattern of it scientists refer to this as antimicrobial resistance it's known as amr and that develops when the microbes that cause an infection they basically evolve ways to protect themselves from that effect that fleming noticed
in his petri dish back in 1928 so that mold that fleming noticed no longer stops the bacteria from growing it's basically driven by a couple of evolution the bacteria just evolves ways around the obstacles that are placed in their way but also by the misuse and overuse of antibiotics in recent years
and that's meant that these antimicrobials antibiotics are becoming less effective and instead we're seeing the emergence of what are called superbugs things like mrsa clostridium difficile known as c diff and the bacteria that cause multi -drug resistant tuberculosis so really serious infections and the range
of drugs then that are available to treat them are becoming fewer so why don't we just discover some new antimicrobials to get around the resistance that's trying to get around the ones we've got already so this is interesting since the 1970s the production of new antibiotics antimicrobials has really
slowed I think the last antibiotic was discovered in the late 1980s and there's lots of reasons for that particularly it's extremely difficult to produce these new drugs it's extremely expensive and it takes a very long time and because of all those reasons the big pharmaceutical companies have shied
away from producing them and in doing so they kind of lost some of the expertise and the knowledge that was available in order to produce these drugs in the first place so a lot of different factors have come together to mean that the production of new antimicrobials antibiotics has really really ground
to a haught we've been talking about resistance to antimicrobials as if it's just a sort of one thing.
Is it or do you have different kinds of resistance?
No, you're right. There are different scales of resistance.
So they talk about multiple drug resistance.
And that's when bacteria developed the ability to kind of resist multiple antibiotics.
But since 2011, and this gives us a clue as to how serious this is, Since 2011, scientists have also referred to different degrees of resistance.
So we have the terms extensively drug -resistant and pan -drug resistant.
So pan -drug resistance is when a microorganism like a bacteria becomes resistant to all known antimicrobial agents.
Basically, that means all approved drugs that are useful for a treatment just stop working.
And there is no backup as such.
there are no readily available alternatives.
And the reason for that is there have been this dearth of new antibiotics since the 1980s.
And in the same way that we call the period up to the 1970s the golden age of discovery, they're now calling that age after the 1980s the discovery void.
So that all means that there are, for some infections, in some parts of the world, there are very, very limited treatment options.
Dom, can I just ask you a personal question?
I mean, you're our global health correspondent, you've been sort of wallowing in all this stuff for a fair old time.
I mean, does it alarm you?
I mean, does it make you think, gosh, sound the alarm, this is a really, really worrying situation?
It is really worrying.
I mean, the World Health Organization estimated that in 2019, around 1 .3 million people died as a direct result of antimicrobial resistance.
and AMR contributed to another nearly five million deaths.
So I was thinking about exactly what you mentioned on the way into the office as I walked in this morning and I was thinking, thank goodness I am healthy, fit -ish and not in a part of the world where I'm likely to get one of these sort of pan -drug -resistant infections.
AMR is now described as one of the top global public health and development threats that we face.
By 2050, it's projected that deaths, both direct and associated with AMR, will hit 10 million a year, and that's going to make it a bigger cause of death than cancer.
So, you know, these antimicrobial medicines, they're the cornerstone of modern medicine.
Drug -resistant bacteria threatens to undermine all of that.
So we've looked at the revolutionary development of antimicrobials.
their massive importance to modern medicine and the threat of developing a resistance to them.
Next, we're going to hear how antimicrobial resistance is being driven by global conflict from Ukraine to Gaza.
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Earlier on, we told you about the near miraculous difference that antimicrobials made to the treatment of battlefield infections when They were first mass produced more than 80 years ago.
But on the front lines in Ukraine, war is rapidly undermining the power of these treatments.
The BBC's Abdul Jalil Abdurasilov has been speaking to soldiers and hospital staff to see how antimicrobial resistance is affecting the ability to treat casualties.
This is what he found.
I recently went to a hospital in Kiev that treats casualties from the front line, and I met a soldier there, Private Alexander Besverkny, who had really serious injuries.
His legs were amputated, shrapnel ripped through his buttocks and abdomen, and as a result, doctors had to remove part of his intestines.
But also, doctors discovered that Private Besverkny had a resistance to antibiotics.
The thing is that most casualties go through several stages of evacuation.
That means they get treated at several different clinics.
When they arrive at the hospital, they get some sort of antibiotics, and then the treatment procedure gets disrupted.
Then they get transferred to another facility where there might be other bacteria around in those hospitals that can infect those patients, and then they get this multi -resistant infection that cannot be treated with commonly used antibiotics.
All medical facilities across the country must deal with the biggest influx of patients that they have had since World War II.
And many hospitals, as a result, they are overcrowded and understaffed at the same time.
So of course, in such conditions, it's much more difficult to keep the facility sterile and to maintain all the procedures to prevent infections from spreading.
The hospital in Kiev where Private Bezverkny is being treated now, they say that more than 80 % of patients they admit have multi -resistant infections or pathogens that can cause them.
And this is exactly what happened to Private Bezverkny.
He nearly died. He had sepsis five times and doctors operated on him more than 100 times.
The problem is that hospitals usually treat these multi -resistant infections with special antibiotics from what they call a reserved list.
But the more often they prescribe them, the quicker those bacteria will adapt to those new special antibiotics and become resistant to those drugs as well.
And as a result, doctors face a dilemma, and I spoke to deputy chief physician at the hospital in Theofania, who explained to me the challenges they face when they treat patients with such resistance.
We have to balance our scales.
On the one hand, we must save a patient.
On the other, we mustn't breed new microorganisms that will have antimicrobial resistance.
We have to save lives, but we also need to restrict the use of certain antibiotics in order to be able to treat our patients in the future.
Private Bezverkny, after spending several months at ICU unit, was finally transferred to a separate ward.
And doctors say that this should be a normal practice, that all patients who have such infections, they must be isolated.
But because the hospitals are so overcrowded, they simply have no space to do that.
And they keep all these patients together and then they contaminate each other as a result of that.
Well, that was the BBC's Abdul Jalil Abdul Rasolov talking about what he found in Ukraine, an extraordinary illustration there of the role of war building up antimicrobial resistance.
Listening to that and still with me is the BBC's global health correspondent.
Dominic Hughes. Dom, is the situation that Abdujjalil just described, is that mirrored as far as we understand in other conflicts?
And I'm thinking particularly, of course, of Gaza.
Yeah, I think it very much is.
I mean, so far, there's no hard data on the most recent conflict in Gaza.
That's not surprising, but it's highly likely that AMR rates have gone up.
We can look at what happened, for example, after what were called the Great March of Return protests in 2018, demanding the end of an Israeli blockade and the right of return for refugees.
Médecins Sans Frontières, the humanitarian organisation, they reported a 300 % increase in antibiotic resistance in bone and tissue cultures and in 2018 MSF says it treated almost twice the number of patients it had the previous year in Gaza reaching around 8 ,000 people now if you think about the casualty
numbers seen in Gaza this time around maybe 100 ,000 it's really hard to get an accurate recent figure but this most recent conflict has touched the lives of so many people that tells you that yes it's highly likely I think that AMR rates will again have just gone through the roof.
And of course what's particularly noticeable in Gaza is the intermingling of civilians throughout the conflict and that presumably ups the risk of increased resistance.
Yeah I think as we heard from Abdu -Jalil lots of different factors come together to drive up the risk of amr developing in the first place so msf says that in conflict affected regions you've got this sort of pretty fragile health system to start with then you have barriers to accessing proper health
care and then environmental contamination you know the sort of thing about not being able to change your rubber gloves between treating patients so in gaza first hospitals have been used as shelters during the conflict and that puts the civilians themselves much closer to centres of disease, then some
of these hospitals have in turn been targeted.
And you combine that with the scale of the injuries, just lack of medical supplies, sick and injured people being regularly released back into the population to make space for the incoming casualties before they have even fully recovered.
Then infections are out there in the general population.
It's not a good scenario.
So it's likely that, you know, AMR is going to impact public health in Gaza.
for years after this conflict ends.
Dom it's absolutely fascinating what you say because I have to say I hadn't thought for a moment about you know war as an accelerant for antimicrobial resistance and yet what Abdul Jalil said what you just say about Gaza it's clearly happening is there anything that can be done to slow the rate or the increase
in the rate of AMR in war zones?
Yeah, I think to start with, some of those problems that have been identified by organisations like MSF in conflict zones, like we've seen in Gaza, they could be addressed through observing the principles of international humanitarian law.
Things like proportionality, distinguishing between civilians and combatants, not bombing hospitals.
That all limits the chances of infection entering in the general population to start with.
Then there are these issues around supplies and medicines, access to good quality microbiology, so you can see what's going on in these patients, all those sort of things.
But it's really, really challenging in a war zone.
And really, really challenging when the war zone is spread throughout society rather than being a battlefield or a front line.
What about in civilian medicine, leaving the war zones for the moment to one side.
How can sort of best practice help limit antimicrobial resistance amongst civilians?
I think it's fair to say there has been a much greater focus on it in recent years.
There's been a really big push on what they call antibiotic stewardship.
Now that means that governments and medical institutions are being called on to promote the responsible and effective use of antibiotics.
So that means not using them too widely for treating conditions on which they'll have little or no impact.
That's especially important in countries where antibiotics are legally available over the counter or you can just get them online without a prescription.
And that comes down to educating us, people, patients, about their usage and managing our expectations is key, managing the expectations of patients.
That leads to the prevention of infections in the first place and that's perhaps even more important than controlling responsible use of antibiotics It's simply because every use of antibiotics carries with it the risk of resistance developing.
We talked about the growth of antimicrobial resistance in war zones and you mentioned that you were pretty pleased you weren't in a part of the world where there were diseases that had become resistant to antimicrobial drugs.
It begs the question, how much of a global problem is this really or is it more about bad luck you've been born there bad luck you happen to be in a war zone no it's a properly global problem it affects high medium low income countries across the world and you know it requires a globally coordinated
response it's very much like covid for example one country just can't take it on alone so in september of 2024 world leaders agreed the first global targets to try and control what is now clearly an antimicrobial resistance crisis there's a whole series of measures the world health organization have outlined
that countries can adopt for example they talk about boosting and encouraging more research into the next generation of antibiotics trying to make it a more attractive proposition for the big pharmaceutical companies and there has been a commitment to actually reducing the number of deaths globally
associated with bacterial AMR.
They want to cut it by 10 % by 2030 against that 2019 baseline of nearly 5 million deaths.
But MSF has said it's good that there's been this acknowledgement of the significant gaps in addressing AMR and what it calls humanitarian and low resource settings.
In other words, conflict zones, much poorer countries.
But they say there's a lack of concrete, really practical steps to try and translate these commitments into tangible action.
A good start, but a long, long way to go.
Exactly that. Dom Hughes, thank you so much for joining us.
It's been brilliant to have you on the show.
Always a pleasure. And thanks so much to you for listening.
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