The struggle for life is a trait shared by all living organisms, not just humans; from the biggest to the smallest, from bears to bacteria. A corollary to our shared struggle for life is a built-in resistance to death: when any form of life is threatened by an enemy, a serious injury, or disease, it fights back. The interesting thing is that regardless of which kind of life is under threat, the fight back — the resistance response — is remarkably similar. You can see this in 3 cases: bacteria’s resistance to antibiotics; cancer’s resistance to chemotherapy; and the French Resistance to the Nazi German occupation during the Second World War. There are dissimilarities too, certainly moral ones, but the value of the comparison is that it offers a crucial lesson about bacteria: they harm that they cause is probably more our doing than theirs.
We begin with the heroic French Resistance because it offers a helpful perspective, one that is too seldom taken into account in health circles: looking at resistance from the point of view of the “organism” under threat, in this case the French citizenry.
The Nazi German invasion and occupation of France during the Second World War constituted an existential threat to French nationhood. In response, resistance cells of small groups of armed men and women sprang up and fought back. They were few in number at first, but their numbers grew as the Occupation became increasingly unbearable. For instance, due to collective punishment — the taking of thousands of hostages from the general population and the shooting deaths of an estimated 30,000 of them — the number of resistance fighters grew to over 400,000 by the last year of the war. And as we know, the Resistance prevailed, the Occupier defeated.
Looking at antibiotic resistance through the same lens, the organism under threat is bacteria. Let’s remember, we live in a bacterial world and the vast majority of them either help us, with things like digestion and immune function, or are harmless. The invader/occupier in this case is the antibiotic; the word means, literally, ‘anti-life’ (bios, from Ancient Greece, means ‘life’). As the NEJM reminds us, antibiotics en masse constitute a huge assault: In 2009, more than 3 million tons of antibiotics were administered to human patients in the United States alone; in 2010, a staggering 13 million tons were administered to animals.
When you’re hit hard like this, you fight back, and so the “bacterial resistance” evolved against all major antibiotics pretty much from the get-go. For example, staphylococcus bacteria developed resistance to penicillin when it was first used in the 1940s; staph then developed resistance to the penicillin-derived methicillin about a year after it was first used in 1960; hence the origin of methicillin-resistant Staphylococcus aureus (MRSA).
However, unlike the French Resistance, the bacterial resistance was slow moving for a quite a number of years. For example, the US death toll from MRSA as recent as 1999 may have been as low as 4 (children). But just over a decade later and commensurate with the antibiotic onslaught mentioned above, the Centers for Disease Control tells us that the bacterial resistance spread across the country and so MRSA now kills more than 11,000 Americans every year and seriously wounds more than 80,000. If you add in other resistant bacteria and cases where “the use of antibiotics was a major contributing factor leading to the illness,” the annual American death toll is close to 40,000 people.
Cancer cells, too, develop resistance to the “assault” from chemotherapy drugs. (There’s certainly nothing beneficial about cancer cells, as there is with bacteria, let alone something heroic about them, as with the French Resistance, but we include them because they also illustrate the principle that all living organisms respond to serious threats by developing resistance to overcome them.)
With cancer cells, as with bacterial cells, drug therapy — chemotherapy and antibiotic therapy, respectively — kills the drug-sensitive cells, but leaves behind a higher proportion of drug-resistant cancer cells. As the tumor begins to grow again, chemotherapy may fail and the patient relapses because the remaining tumor cells are now resistant. In fact, one way cancer cells resist chemotherapy is similar to how bacterial cells resist antibiotic therapy: molecular “pumps” actively expel drugs from the interior of the cell.
The lesson in all of this is explained by infectious disease specialist Brad Spellberg, MD, chief medical officer of the Los Angeles County and University of Southern California Medical Center. His point is that we have to change how we think about the bacterial world. We need to shift our approach from one based on confrontation to one based on co-existence. Thus, for example, the language of war metaphors of invasion, defense, destroying the enemy, and so on, should be abandoned because those words fundamentally misdiagnose what bacteria are about. Instead, Dr. Spellberg suggests this approach:
I like to go back to first principles before I tackle complex problems. This whole thing about winning the war against microbes … nah!
We’re not going to win a war against organisms that outnumber us by a factor of 1022 , outweigh us by a hundred million-fold, replicate 500,000 times faster than we do, and have been doing this for 10,000 times longer than our species has existed!
So what we need to do is flip it around. We’re not at war with them. What we need to do is, in the immortal words of Dave Gilbert, achieve peaceful coexistence. The question is, what strategy do we deploy to achieve peaceful coexistence?
I think we need to start thinking of infections, by and large, in most cases, as accidents. There is no advantage for bacteria in most cases to infect us. They are much better off being non-infectious commensals in our gut.
In this sense, then, our massive overuse of antibiotics is simply fertilizing disease, death, and pain. So much so that the figure mentioned above of 40,000 American deaths a year caused by the “bacterial resistance,” rivals the annual death rate of any war the US has ever been in with the exception of their Civil War.
At the end of the day, says Dr. Spellberg, it comes down to “our wits versus their genes,” and the job of our collective wits is simply to come to grips with one fundamental truth about resistance:
This is what bacteria do. They’re just being bacteria. They become resistant to stuff, they adapt. We have to accept that’s never going to stop. No matter how perfect our stewardship is, no matter how prefect our infection control is, they’re always going to adapt. So, yes, we are never going to win in the end. But … we know steps that we can [adopt] to get back ahead in the race.