The Looming Super-Bug Crisis: China's Battle Against Antimicrobial Resistance

As the world finally begins to step out of the shadow of the COVID pandemic, another global health emergency is at the doorstep. The emergence of super-bugs, or pathogens resistant to multiple antibiotics, poses an escalating challenge to global health with consequences that could rival or even surpass the previous pandemic. The phenomenon of antimicrobial resistance (AMR) has moved from a looming threat outside the realm of possibility to a completely plausible reality in which surgeries, car accidents, or even tattoos are deadly.

The People's Republic of China, with its vast population and global connections, is at the forefront of this battle against AMR. The nation's unique set of challenges, from healthcare system issues to the high prevalence of resistant strains, places it under the microscope in the global effort to understand and combat the rise of super-bugs. With this in mind I argue that there is a 40% chance of a super-bug, resistant to a broad spectrum of antibiotics, emerging from China by the year 2035.

Why Fear the Super-Bug

Super-bugs, a term broadly used for pathogens resistant to multiple antibiotics, pose a significant threat to public health and left unchecked, human civilization. These include resistant strains of bacteria, viruses, parasites, and fungi. Common examples are bacteria causing pneumonia, urinary tract infections, and skin infections. Drug resistance, or antimicrobial resistance (AMR), is a natural phenomenon wherein bacteria adapt to medications designed to eliminate them. The resistance is accelerated by the use of antibiotics, creating evolutionary pressure for bacteria to develop resistant forms.

In China, the rise of super-bugs has placed considerable strain on the healthcare system. A notable instance was a large wave of Mycoplasma pneumoniae infections in September of last year. This bacterium typically causes mild infections akin to a common cold but can lead to more severe conditions in children. The outbreak resulted in overwhelming pediatric care centers and widespread social media reports of overcrowded facilities and extensive waiting times for medical attention. The majority of infections are usually resolved by individuals themselves or through the use of over-the-counter medicines to mitigate symptoms. More severe cases, however, often demand antibiotic treatment. This is a grave issue since China experiences high occurrences of macrolide-resistant mycoplasma pneumoniae. In adults, 60%-70% of such cases and up to 80% in children are resistant to commonly used anti-biotics such as Zithromax and other comparable drugs.

In 2016, China witnessed a significant development with the identification of the MCR-1 gene, known for its ability to resist colistin, an antibiotic used as a last line of defense. Furthermore, 2021 data from the China Antimicrobial Surveillance Network revealed shockingly elevated resistance levels for multiple bacteria: Klebsiella pneumoniae showed a 24.4% resistance to meropenem, Pseudomonas aeruginosa had an 18.9% resistance rate, and a striking 72.3% of Acinetobacter baumannii strains were resistant.

The potential global implications of a super-bug originating from China are substantial. The early stages of the COVID-19 pandemic serve as a stark reminder of how rapidly a pathogen can spread globally. Moreover, the authoritarian nature of China's government system, which often prioritizes controlling information over transparent reporting, could exacerbate the situation by delaying global response efforts. Consequently, a super-bug emerging from China could spread swiftly first domestically while central authorities repeat the same mistakes made in the beginning stages of the COVID pandemic.

How it’s Happening

China's healthcare system, characterized by its fragmented structure, fosters an environment conducive to corruption and the over-prescription of drugs. The intense competition within the healthcare sector pushes doctors towards practices such as over-prescription. Corruption also plays a role in the AMR build-up. Corruption in China's healthcare is predominantly manifested through bribery, embezzlement, and insurance fraud. A significant portion, around 80%, of bribe-takers are healthcare providers, with bribes mainly coming from pharmaceutical, medical equipment, and consumable suppliers and most bribe-givers were suppliers of pharmaceuticals, medical equipment, and consumables. The fragmented nature of China’s pharmaceutical industry leads to fierce price competition over market share which incentivizes pharmaceutical companies to bribe hospital administrations to purchase their supply in order to gain market share.

The root causes of these corrupt practices by healthcare providers are often financial pressures and weak oversight. Healthcare providers, facing economic and social pressures, resort to accepting kickbacks to supplement their income. This corruption escalates health expenditure, undermines the accessibility of health services, and adversely impacts the quality of healthcare, promoting both over-prescription and overtreatment. It also strains doctor-patient relationships and hinders progress in the pharmaceutical industry and medical innovation.

Additionally, despite regulations against selling antibiotics without prescriptions, enforcement is lax. A cross-sectional survey across 13 provinces revealed that 83.6% of pharmacies dispensed antibiotics without a prescription. The study also found that antibiotics were provided upon the first or second request in many cases, a glaring systemic issue with huge implications. Furthermore, a 2019 survey on Weibo, involving more than 2,000 participants, revealed that antibiotic use is relatively common, with nearly half (47%) of respondents reporting antibiotic use in the past six months. In this same survey a lack of knowledge about what antibiotics can and can’t treat becomes evident. Most survey participants correctly identified antibiotics as suitable for urinary tract infections (86%) and skin infections (76%). However, a notable proportion mistakenly thought antibiotics could treat viral illnesses such as measles (32%) and colds or flu (26%). This information coupled with research conducted in 2020 that shows patient and caregiver pressure on physicians to prescribe them antibiotics significantly contribute to AMR growth.

The recent anti-corruption campaign targeting healthcare system corruption, addresses only part of the issue. The crackdown focuses on physicians and hospital administrators accepting bribes or kickbacks from pharmaceutical companies. However, this approach neglects other contributing factors like patient expectations and knowledge along with the availability of antibiotics over the counter. Consequently, while these measures might curb some corrupt practices, they fall short of addressing the multifaceted nature of the problem, including cultural and systemic aspects that drive antibiotic overuse.

Progress being made

In response to the escalating challenge of antimicrobial resistance, the People's Republic of China has mobilized an extensive array of policies and actions aimed at mitigating this pressing health issue. Central to these efforts is a collaborative framework led by the National Health Commission.

In October 2022, the National Health Commission, in a collaborative effort with 12 other ministries and commissions, introduced a comprehensive action plan aimed at controlling major pathogens affecting both humans and animals. Central to this plan are five primary goals, however we will focus on three. The first goal aims to slow the emergence of resistant organisms and prevent the spread of resistant infections. This is pursued by minimizing the unnecessary use of antimicrobial agents across humans, animals, and agriculture, coupled with extensive public and professional education about antimicrobial resistance. The second goal strengthens the national health surveillance network monitoring AMR. This involves developing an expansive surveillance network that covers human, animal, and plant populations as well as the environment. This network is integrated with existing surveillance systems and is supported by an innovative online real-time early warning system for multi-drug resistant organisms. The third goal is to accelerate the research and development of new antimicrobial agents, vaccines, and diagnostics. It promotes multidisciplinary collaboration to advance core technologies and significant products for AMR prevention and control. A key objective under this goal is the development and marketing of novel antimicrobial agents and diagnostic tools by 2025.

Complementing these efforts, the National Institute of Hospital Administration has been proactive in educating healthcare professionals through a series of initiatives. Since 2015, programs such as the 'Peiyuan project', 'Peiying project', 'Peiwei project', and 'SHIP project' have been rolled out. These programs are tailored to different groups of healthcare professionals - clinicians, clinical pharmacists, microbiology technicians, and infection control specialists, respectively. The objective is to enhance understanding and practical skills necessary for effective AMR management in clinical settings. The focus on education makes it clear that informed and well-trained healthcare professionals are a key part of tackling the AMR challenge.

In addition to these policy efforts, during the most recent outbreak of Mycoplasma pneumonia Beijing took a different approach than what it did with during the opening months of the COVID pandemic. The World Health Organization (WHO) made a rare public request to China for detailed data on "clusters of undiagnosed pneumonia in children in northern China." This included a call for epidemiologic and clinical information, as well as laboratory results related to the infections. Following the WHO's request, Chinese health authorities arranged a teleconference with the WHO to provide the requested data. The WHO's request and subsequent public statement likely reflect ongoing concerns about Beijing's transparency in sharing public health data, a concern well founded by China’s early response to the Covid-19 pandemic.

China's pharmaceutical industry is also a bright spot for future innovation. The industry’s Enhanced Efficiency of Economic Transformation (EETS) points towards that the central and western regions of China are showing more robust progress in transforming research and innovation into practical, economic outcomes. The trend is a positive shift in the search for crucial advancements in combating super-bugs. The diversity of medical needs, including the fight against unknown diseases and drug-resistant pathogens, is also propelling continuous innovation within the pharmaceutical sector. The development of new drugs and therapies not only meets immediate healthcare challenges but also opens new market opportunities.

While the threat of a super-bug emerging from China is real and carries a 40% likelihood by 2035, the strides made by the Chinese government and the global community in addressing antimicrobial resistance offer a beacon of hope. The proactive policies, innovative research, and increasing transparency in China's healthcare sector are significant steps toward mitigating this risk. However, progress must be made towards properly educating people on what antibiotics can and cannot help with along with preventing the selling of antibiotics without a prescription if Beijing wants to avoid a second cataclysmic global health disaster.