10 February 2022
Staphylococcus aureus bacteria. Image: Scientific Animations via Wikimedia (CC BY-SA 4.0)
South Africa’s national action plan against antibiotic resistant bacterial infections — one of the world’s great health crises — remains unfunded. Seven years after commitments were made at the launch of South Africa’s Antimicrobial Resistance National Strategic Framework, we are still on a list of countries which are able to celebrate having nice documents but not putting their money where their mouths are to execute them. Our government’s report card reads “Must do better”.
The first four articles in this series on the pandemic of antibiotic resistance have explained the extent of death and illness it causes, what’s driving it, and what individuals can do to try and prevent a resistant bacterial infection. But some things must be done at government level, and here we are failing dismally.
Our increasing epidemic of difficult-to-treat bacterial infections demands a more vigorous response from all government ministries but especially Health, Agriculture, Environment and Treasury.
The implementation of South Africa’s national action plan falls within the Essential Drugs Programme of the National Department of Health, which is also responsible for producing the national essential medicines list. Human resource limitations are stifling its work. The four pharmaceutical policy specialists who are responsible for this and other critical programmes have a single assistant, on loan, to help with some of the administrative work.
Before Covid, face-to-face meetings of the Ministerial Advisory Committee on Antimicrobial Resistance were funded by the health department but any other activities involved going “cap in hand” to partners such as the US Centers for Disease Prevention and Control (CDC), the World Health Organisation and others. National awareness campaigns on antibiotic resistance have been impossible due to lack of funding.
Antibiotic misuse and abuse occurs in humans, animals and the environment. But the lack of funds for a national action plan and lack of support for those who are tasked with delivering it, suggest that the health, agriculture, and environment departments are not taking antibiotic resistance seriously. Requests for meetings with ministers, and for representatives to sit on committees and technical working groups, have largely fallen on deaf ears due to a lack of leadership.
Article three in this series explained how preventing infections is crucial in tackling antibiotic resistant bacterial infections. Yet it has taken more than a decade to persuade successive health ministers to appoint a national focal point for Infection Prevention and Control, to lead the cadre of health workers that keep patients in hospital safe from contracting an antibiotic resistant bacterial infection. The post only has funding for two years from the Council for Scientific and Industrial Research, and comes with no financial support for implementation of programmes.
Without leadership at the top, the health department’s attempts to improve patient safety and limit the need for antibiotic use in hospitals has floundered countrywide. Also, there is no national programme of active surveillance for hospital-acquired infections, so we have no idea of the true burden. From experience however, let’s just say that hospitals are not quite the safe haven that they should be.
Preventing sickness in the population reduces the number of people who venture to a doctor only to be given an antibiotic, which, half the time, is not required.
The Global South remains shackled to bacterial infections largely because of our inability to reverse many of the social determinants of infectious diseases. Although one cannot alleviate poverty in one fell swoop, the provision of clean water and safe sanitation to everyone would be a major intervention to reduce viral diarrhoeal diseases for which antibiotics are abused.
Also, increasing vaccination coverage for the extended programme of immunisation in children, and an adult vaccination programme for vulnerable people, would have a major impact on pneumonia and diarrhoeal diseases, major childhood killers.
Similarly, it will take wide-scale investment to reduce antibiotic abuse in food-producing animals in South Africa. Infection prevention on farms will need to be improved — best achieved through regular vaccination — and that costs money.
In 2007, South Africa had a thriving surveillance programme for bacterial resistance in animals, which collected information from each of the nine provinces. That programme fell apart once grants from the National Research Foundation and the Swedish government came to an end. We now identify only a tiny fraction of the bacterial resistance levels in food production in South Africa. Ignorance, in this case, is not bliss. These bacteria enter the food chain and affect humans, so it’s vital that we know the full extent of what’s out there.
So what needs to happen? First: leadership. We need far greater engagement with antibiotic resistance from President Cyril Ramaphosa and his administration.
There is a long list of “repairs” to be made:
This last point will require the health department to meet the international standard of one infection control practitioner for every 250 beds. Many hospitals across the country have none, and few meet the target. Without these vital practitioners, our hospitals are less safe and we are left to tackle the in-hospital transmission of antibiotic resistant bacteria with one hand tied behind our backs.
Funding must be found for public awareness and education programmes on bacterial resistance including in schools and universities, helping the country understand the problem and how to protect itself.
Research into new antibiotics is nice to have, but this particular pandemic won’t be ended by a new antibiotic or diagnostic test any time soon. The South African Medical Research Council and other funding bodies are already doing what they can to invest in the science of bacterial resistance, but more investment would be welcome from government and outside funding agencies.
Unfortunately, the global North’s focus on research and development brings up a problematic area in global health. The interests of the rich nations are not necessarily aligned with ours in the Global South. This is becoming increasingly true for antibiotic resistance.
Naturally, new antibiotics will temporarily help against bacterial resistant infections. But resistance to those new antibiotics will quickly develop. Moreover, the main driver of bacterial resistance in the South is the sheer extent of infectious diseases with which people come to doctors. So while rich nations that dictate global agendas are pouring money into the search for new antibiotics, the really significant interventions to prevent infections in the global South remain unfunded and undervalued.
This brings us back, full circle, to leadership. It’s already late in the day, but about time that leaders in low and middle-income countries, including South Africa, drive the antibiotic resistance agenda on the world stage towards the needs of the global South.
Covid funding has shown us that where there’s a will there’s a way, and billions of dollars in finance can be found for public health. It’s time to recognise what antibiotic resistant bacterial infections are doing to the lives of millions of people in the global South, their companion animals, and the food we eat. Our leaders must invest in a future where antibiotics continue to benefit every one of us, north and south of the equator.
