Dr. Bill Frankland, a 106-year-old allergy expert, is one of the precious few still alive to remember Alexander Fleming’s discovery of penicillin, as well as the warning that followed just eight years later. Franklin recalls, “Fleming said there would be a revolution, but doctors will overuse it, and because bacteria have to survive … they will become resistant to it.”
Fleming’s predictions came true, and the link between antimicrobial resistance and antibiotic use is well established. Countries around the world are still coming to grips with ways of rationing such drugs to limit the development of antibiotic-resistant bacterial strains. But it’s not just wealthy Western countries overusing the technology. In fact, according to a World Health Organization survey of 65 countries …
PEOPLE IN MONGOLIA ARE THE WORLD’S MOST PROLIFIC USERS OF ANTIBIOTICS, WITH AN AVERAGE OF 64.4 PEOPLE PER 1,000 ON ANTIBIOTICS ON ANY GIVEN DAY.
Not only that, but Mongolia’s usage was nearly twice as high as the runner-up, Iran, which had an average 38.78 people per 1,000 on antibiotic treatment per day. This doesn’t mean Mongolia has more antibiotics, in terms of volume — that would actually be Turkey, which consumed 1,195.69 metric tons of antibiotics in 2015 — but that those in Mongolia are the most likely to use antibiotics.
Dr. Moazzam Ali, an epidemiologist who’s researched the irrational use of drugs while based at the University of Tokyo, Japan — including the use of non-prescribed antibiotics in Mongolia — says that two of the most common uses of antibiotics in low- and middle-income developing countries is pneumonia and diarrhea. “It might be a simple flu, but they would treat it with antibiotics. This is especially the case when it comes to treating children,” he says. A 2010 study he undertook with other researchers in Mongolia found that 71 percent of children in the 503 households studied were given prescribed antibiotics, and a fifth of them had been given non-prescribed antibiotics as well. Just under half of the caregivers would give children antibiotics for a cough, fever or cold, and a survey showed they largely lacked basic knowledge about the proper use of the drugs.
WHO spokesperson Christian Lindmeier says higher antibiotic use can be attributed to the “disease pattern” in Mongolia. Respiratory and genitourinary tract infections are the first and fourth leading causes of death in the country, and people use antibiotics to treat both of them. He also cites tuberculosis as a leading problem, including multidrug-resistant strains, which he estimates were behind 8.5 percent of registered new cases of communicable diseases in 2017. “The high burden of communicable diseases contributes to the use and overuse of antibiotics,” he says.
Since 2001, it’s been illegal to supply drugs like penicillin over the counter, but it still happens. While the laws are in place, the regulatory mechanisms for oversight are fragmented and duplicated over different authorities, resulting in weak enforcement.
The number of private pharmacies in the country rose quickly after the Mongolian revolution in 1990 — a country assessment report by the Mongolian Development Research Institute indicated that between 1995 and 2004, the figure nearly increased eightfold from less than 100 to circa 800 — and the introduction of a free-market economymade drugs easier to buy, as they could be bought over the counter.
One 2013 study, by researchers at Curtin University and the Curtin Health Institute in Western Australia, that surveyed 22 pharmacies, 118 doctors and 394 patients in both rural and urban areas of Mongolia even found that practitioners themselves would wrongly prescribe antibiotics in some instances, particularly in urban centers. In rural areas, they have their own problems, with the lack of qualified doctors and drugs being difficult to access, at least the right ones. Ali notes, however, that even traditional healers, found mostly in the countryside, might use antibiotics in whatever concoction they end up making, which could include a number of other drugs.
“When you talk about antimicrobial resistance, it’s knowledge and information that matters; educational status matters,” says Ali, noting that the older generations commonly believe that antibiotics are a cure-all, regardless of whether the person’s condition actually will be helped by taking one.
According to Laura Rogers, deputy director of the Antibiotic Resistance Action Center at the Milken Institute School of Public Health, at George Washington University, doctors have noticed antibiotic resistance building for decades — but 30 years ago, they tended to operate on the belief that new antibiotics could always be created to outmaneuver the bacteria. It wasn’t until a 2014 report on antimicrobial resistance commissioned by the U.K. government that the world really woke up to the problem. And in Mongolia, awareness-raising programs — currently one of WHO’s key priorities — only really started around two years ago.
Mass education is only part of the solution, though. Other key factors would include establishing an effective drug regulatory authority to improve enforcement of the law against non-prescribed drugs and strengthening surveillance systems to get more information about patterns, trends and consumption habits. It’s not only human antibiotic use that should be monitored either: Use of antibiotics in animal feed is also widespread in Mongolia, according to WHO, a practice that has been used globally to hasten production but could have harmful effects for both animal and human health as it breeds drug-resistant germs that can then jump to humans. Livestock accounts for 83 percent of the country’s agricultural sector, and exports of meat rose an estimated 20 percent between 2017 and 2018.
Health professionals are quick to note that the message here is not for people, in Mongolia or elsewhere, to stop taking antibiotics. Countries like Burundi, which had the lowest levels of antibiotic use in the WHO survey, are setting off their own alarm bells. While the overuse of antibiotics is a critical problem, the lack of access for those who need them can’t be ignored either.