[Editor’s note: This is the first in a series of posts covering topics related to drug resistance, including causes, effects, what is being done to fight drug resistance, and what needs to be done to limit the harm caused by drug-resistant pathogens.]

The discovery of penicillin in 1928 was one of the greatest medical discoveries to date, and since their introduction, penicillin and other antibiotics have saved an incredible number of lives. Unfortunately, it didn’t take long for the bacteria to fight back.

The discovery of penicillin-resistant bacteria within a year of the first clinical use of the antibiotic would serve as a sign of things to come. Today, there are few (if any) widely used antimicrobial drugs that have not been rendered less effective by the emergence of resistant pathogen strains. The fast replication cycles of bacteria and viruses and the mistakes made by their replication machinery give these pathogens the ability to respond to and overcome drug pressures. With penicillin, for example, replication errors allowed some formerly penicillin-sensitive bacteria strains to evolve so that the targeted bacterial proteins no longer interact with the antibiotic. Other bacterial strains acquired new genes that allow them to produce proteins that degrade penicillin, rendering it ineffective and allowing these bacteria to survive.

Drug resistance continues to be a major obstacle in reducing the prevalence of the “big three” infectious diseases: HIV/AIDS, tuberculosis (TB), and malaria. The recent emergence of malaria strains resistant to artemisinin, one of the most effective anti-malarial drugs and sometimes the only drug that can effectively kill the deadly Plasmodium falciparum parasite, serves to highlight how troublesome — and downright frightening — drug resistance can be.

Of course, drug resistance is not just a problem for the “big three.” Drug-resistant strains of H1N1 (swine) flu have been found in Canada, Denmark, Japan, and Hong Kong, which does not bode well for the upcoming flu season. Drug-resistant staph infections are also a significant problem. It has been estimated that methicillin-resistant Staphylococcus aureus (MRSA) was responsible for 94,360 infections and 18,650 deaths in the US in 2005.

Drug resistance is not just a public health issue — it is also a human rights issue. Article 25 of the Universal Declaration of Human Rights acknowledges the right to medical care, and as one of humanity’s greatest achievements in medicine, antimicrobial drugs are a necessary part of adequate medical care. Unfortunately, the actions of doctors, pharmacists, consumers, and others — and the lack of appropriate action by governing bodies — continue to promote the emergence and spread of drug-resistant pathogens. Of course, the emergence of drug-resistant pathogens is not in itself a human rights violation, but the (mis)handling of drug-resistance issues by medical and public health practitioners clearly has human rights implications. Human rights implications arise from the fact that much can be done to reduce the emergence of resistant pathogens and to ensure that people will have access to life-saving antimicrobial drugs when they are needed.

Here, MRSA serves as a good example. It has been shown that active surveillance measures in hospitals can reduce hospital-acquired MRSA infections. However, many hospitals in the US have failed to implement such programs. Typically, surveillance programs are not adopted because of high cost or limited resources, even in wealthier countries.

But what about the people who get MRSA infections during their hospital stay? If surveillance programs are evaluated from a human rights perspective, these programs can be viewed as protecting people’s right to health by protecting them from potentially deadly MRSA infections. Put another way, hospitals that decide not to implement surveillance programs are depriving patients of that protection of their right to health. A person’s right to health should not be denied without an extremely compelling reason (for example, because doing so would greatly infringe upon the rights of others) and should certainly not be done simply because of (bearable) cost, inconvenience, or plain unwillingness to adopt life-saving measures.

Human rights issues also come into play when determining how to respond to outbreaks of disease caused by drug-resistant pathogens. In these situations, the rights of a few (the infected individuals) are often in conflict with the rights of many (the general public). Striking the proper balance between protecting the rights of both groups has been a difficult thing to do.

Attaining that proper balance has been widely discussed with respect to multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB, including in a recent Health and Human Rights article. On one hand, the public needs to be protected from the disease, prompting calls for compulsory treatment and quarantine of individuals infected with MDR- or XDR-TB. On the other hand, such measures — particularly forced quarantine — infringe upon the rights of the infected individuals. The example of MDR- and XDR-TB demonstrates the need for medical and public health practitioners and policy makers to consider human rights implications when determining the best response to outbreaks of drug-resistant disease.

Because drug resistance further complicates already complicated issues surrounding infectious disease control, it is imperative that human rights and public health practitioners understand drug resistance so that infections with drug-resistant pathogens can be prevented and treated in ways that best protect the rights of everyone involved.

More Information:

WHO: Drug resistance

CDC: Antibiotic/antimicrobial resistance

The New England Journal of Medicine: Artemisinin Resistance in Plasmodium falciparum Malaria

Infection Control and Hospital Epidemiology: Society for Healthcare Epidemiology of America guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus

Airborne: A Journey into the Challenges and Solutions to Stopping MDR-TB and XDR-TB is a powerful new book written by John Donnelly that features interviews and images to put a human face on the TB epidemic across the world. In her foreword, WHO Director-General Margaret Chan wrote, “I urge you to read the personal stories collected in AIRBORNE. These are human tragedies that should never have happened. But these are also stories about the uplifting success possible when the right elements are in place.”

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Australian Abortion-Aid Ban Lifted

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In Reversal, US to Engage with Human Rights Council

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Living in a Sea of Mud and Drowning in Dread

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Chad: Fighting Violence Against Women — But How?

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In Iraq, A Story of Rape, Shame and ‘Honor Killing’

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Mentally Ill and in Immigration Limbo

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Women’s Health Insurance Fairness Act

U.S. Senator John Kerry has introduced a bill that would prohibit health insurance companies from charging women higher premiums and from discriminating against women based on whether they are pregnant.

When Dr. Jennifer Furin started treating patients in Lesotho at the Nohana Health Center in July 2006, many of her patients had never had access to a doctor. In fact, after walking hours up and down mountains to reach a clinic, patients would often find it locked and unstaffed. If the clinic was open, basic medicines and supplies were scarce, and the nurses could offer little comfort to their patients who were suffering from highly infectious diseases such as HIV/AIDS and tuberculosis. Almost none of the patients – in spite of HIV rates in Lesotho approaching 30% – had ever been tested for HIV, let alone had access to lifesaving anti-retroviral therapy (ART). A mere handful of patients were being treated for TB.

Nohana is one of approximately fifty health clinics scattered across the mountains in rural Lesotho – each more logistically challenged than the next. About a dozen of these remote clinics (including Nohana) have access to a nearby airstrip – enabling staff and supplies to arrive from the capital, Maseru, in approximately 30 minutes. Via land, the treacherous trip from Maseru to Nohana would take 6 hours or more by car, traveling the edges of steep mountains on barely visible dirt paths. Now, with assistance from the pilots and planes of Mission Aviation Fellowship (MAF), the Partners In Health Lesotho (PIHL) team can adequately supply and staff these clinics, ensuring that they are open and that care is available whenever our patients make the long journey to seek medical treatment.

In February 2008, a small team from the Harvard News Office visited two of the PIHL mountain clinics – Nohana and Bobete. They were able to capture the essence of our programs in Lesotho via stunning text, photos, and video – accessible here. I’d like to direct you to a two part photo/video story filmed in Nohana, featured below. It is the story of Kazabelo – a tiny, malnourished 15-month-old baby on the edge of death.

For Kazabelo, the story ends well – at least in the short term. She has survived this round of her life’s battle, and is a plump and healthy toddler (see picture) less than six months later.

Whether our patients come to Nohana, Bobete, or one of the four other remote clinics operated by PIHL in four of Lesotho’s most rural and mountainous districts, the care they receive is essentially the same. We staff each of our six clinics with a full-time physician, who is trained in management of HIV/AIDS and TB as well as primary care and trauma. In addition to treating patients, the PIHL physicians work closely with clinic nurses who are paid by the Lesotho Ministry of Health and Social Welfare – training them in infectious disease management and other critical skills. The doctors and nurses are supported by a cadre of lay health workers, who handle various administrative tasks – including HIV testing and counseling, and food distribution.

The physicians also hire and train Community Health Workers (CHWs) – the key to finding and treating so many patients in the remote villages served by our clinics. Our CHWs visit HIV patients daily to ensure that they are taking their medications properly and consistently, and to check for side effects and other problems of poverty (such as lack of food or water) which might interfere with treatment. CHWs are the vital link between clinic and community, encouraging neighbors and friends to visit the clinic for testing and treatment, notifying the doctors when patients are too ill to make the long journey themselves, and supporting chronically ill patients through months and even years of treatment for HIV/AIDS and TB.

Unfortunately, Kazabelo’s painful story is not unique. There are far too many underweight, malnourished infants and children in Lesotho – and worse, many of them do not arrive to our clinics in time. In a country where an entire generation of adults is being wiped out by the dual epidemics of HIV & TB, too frequently very young children are left in the care of their aging grandmothers. Current estimates peg the orphan rate in Lesotho between 16 and 30% – very likely the highest per capita orphan rate in the world. How old will Kazabelo be when her grandmother can no longer care for her? Will she survive long enough to witness the right to health care become a right realized by everyone in Lesotho?