Tackling anti-microbial resistance: Updated ways to approach an intractable problem

The complex and refractory problem of antimicrobial resistance (AMR) is posing an ever-more serious threat to human health. Norway have employed a successful national strategy since 1998 to combat this problem, and Norway is now one of the lowest-prescribing countries in Europe. However, to ensure continuing success, Professor Guri Rørtveit of the University of Bergen, Norway urges a contemporary approach to accompany traditional ideas, re-framing AMR under the paradigm of two philosophical concepts: ‘super wicked problems’, and ‘post-normal’ science.
When we think of antibiotics, 20th century scientist Alexander Fleming often comes to mind. In 1928, Fleming returned to his messy laboratory after a break in Suffolk and observed that a fungus known as Penicillium notatum had grown on a culture plate of Staphylococcus bacteria he had left unattended. He discovered that in the areas that the fungus had grown, the bacteria had died. This inspired him to culture the mould and experiment with how effective it would be when diluted. Thus, the modern birth of antibiotics.

However – humans have been harnessing the antimicrobial properties of antibiotics for millions of years. Scientists in the 1980s discovered traces of tetracycline in ancient human bones from Nubia (a region between northern Sudan and southern Egypt, along the Nile River) that were approximately 1,600 years old. Researchers concluded that the beer they drank was likely the source – the grain they fermented to make the beer contained the bacteria streptomyces, which produces tetracycline. Whether this contamination was routine or accidental remains a mystery. Moreover, evidence exists that mouldy bread was used to treat infected wounds in ancient Egypt, China, Greece and Serbia.

Antibiotic resistance
The mass production of antibiotics profoundly revolutionised modern medicine. However, the continued use of this ubiquitously useful drug comes at a steep price – antibiotic resistance. Antimicrobial resistance (AMR) is often thought of as a contemporary problem – however, scientists in 2016 found that the gut bacteria inside ancient Incan mummies (approximately 1000 years old) are resistant to the majority of the antibiotics available today.

From this we can see that antimicrobial resistance is a naturally occurring process, but is exacerbated by the overuse of antibiotics. An example of this is the over-prescription of antibiotics and the availability of over-the counter antibiotic products in many countries. The overuse of antibiotics has led, in part, to the formation of ‘superbugs’ such as methicillin-resistant Staphylococcus aureus (MRSA), multi-drug resistant tuberculosis and penicillin-resistant Gonorrhoea – all of which pose a serious risk to health.

Norwegian national strategy for tackling AMR
Since 1998, a national strategy has been in place in Norway to combat anti-microbial resistance, and a specialist team was created within the Norwegian Ministry of Health and Social Affairs to address the issue of AMR. This group delivered a plan of action in their 1999 report, which led to the establishment of the ‘Norwegian Surveillance System for Antibiotics Resistance in Microbes’. Following this, an updated report was published in 2014, upon which the current strategy is based, and which mimics the World Health Organizations’ (WHO) global action plan for tackling AMR. This strategy involves four government ministries; Health and Care Services; Trade, Industry and Fisheries; Agriculture and Food; and Climate and Environment. The four overarching goals include: reducing the total use of antibiotics, ensuring antibiotics are used correctly, increasing the knowledge surrounding the causes of AMR and engaging in international collaboration to bolster the correct use of antibiotics.

Further to these overarching goals, there are also several specific goals set for the healthcare sector: antibiotic use to be reduced by 30% (compared to the 2012 level), Norway to become one of the three lowest prescribing countries in the EU, prescription rates to be reduced (from 450 to 250 per 1000 patients), prescription rates for respiratory infections reduced by 20% (compared to the 2012 level) and to conduct studies exploring possible consequences of infrequent antibiotic use and AMR burden of disease.

Restricting antibiotics: draconian, but for the greater good?
By 2020, the goals outlined in the national strategy were almost reached, even though Norway has an already low level of antibiotic prescription. However, a new concern is possible adverse effects of low antibiotic prescription rates on the health of the public. In a ‘catch-22’ situation, general practitioners (GPs) lack the necessary diagnostic tools to distinguish patients who are likely to develop a severe condition from an aggressive bacterial infection, compared to those who may have a condition of viral origin (on which antibiotics are useless) and may clear up unaided. In short, low antibiotic prescription rates will inevitably lead to more serious illnesses developing in some patients. Professor Guri Rørtveit, of the University of Bergen, therefore stresses that we must strike a balance between maintaining the health of the population for now, with the suffering that will come if our current antibiotics become useless in the future. Furthermore, we must not lose the confidence of the populace, as strong alliances between healthcare providers, public health authorities and the public has been essential to the success of the current strategy.

“Professor Rørtveit stresses the importance of remembering that no one group of specialists holds the ultimate answer to AMR.”

A philosophical approach: super wicked problems
Two science-related philosophical approaches have been used by Professors Rørtveit and her colleague Skov Simonsen to help frame the problem of anti-microbial resistance: the concept of a ‘super wicked problem’ and the related concept of ‘post-normal’ science.

A ‘super wicked problem’ is a phrase first used in 1973 to describe a complicated social problem so multi-faceted and complex that the only realistic hope of a positive outcome is simply to minimise the negative repercussions it brings about. There are many varying descriptions of a ‘super wicked problem’, but most sources agree that the main characteristics of super wicked problems are: the time left in which to solve the problem is running out; those who can help solve the problem are also partly causing it; the mandate (a command to do something) is insubstantial; and people are unwilling to act now in the interest of solving a future problem. It is important to note that a super wicked problem does not denote simply a serious or difficult problem. Global warming is a further example of a super wicked problem, and framing AMR as a ‘super wicked problem’ may help us understand the complexity and extent of the problem.

Post-normal science and AMR
To understand the concept of ‘post-normal science’ and how it is applicable to AMR, we must first briefly explore the concept of ‘normal’ science. ‘Normal’ science is explored in American physicist Thomas Kuhn’s book The Structure of Scientific Revolutions in which he established a theory about how scientific paradigm shifts occur. Science, Kuhn says, generates results within the theoretical framework, accumulating anomalies (which are normally explained as errors). Over time, these anomalies build up until a time is reached where it no longer makes sense to explain the anomalies away as errors, therefore birthing a new theory to accommodate these anomalies. This then results in a fundamental scientific ‘paradigm shift’ in which the new theory is established as correct, and is eventually taken for granted.

This process is an ongoing cycle that accompanies all theoretical scientific discoveries. An example of this would be Copernicus’s claim that the Earth orbits the sun, and is not the centre of the universe.

Within the parameters of ‘normal’ science, uncertainty tends to be disregarded, whereas in ‘post-normal’ science (a framework developed by Funtowicz and Ravetz, in 1993) this element is viewed as essential in the way we must frame problems such as AMR. In times where facts are uncertain, and the stakes are high, the outcome has the potential to be devastating or highly successful, as values are disputed (this may be political, moral or economic in nature) and decisions are urgent. Professor Rørtveit believes we must open-mindedly apply the concepts outlined above in order to understand the scope and magnitude of AMR.

A united front
Furthermore, Professors Rørtveit and Skov Simonsen stress the importance of remembering that no one group of specialists holds the ultimate answer to AMR. Politicians and scientists must work together with healthcare professionals and the public, employing a ‘one health’ perspective (a multi-sectoral, transdisciplinary approach) and accompanying traditional strategies to combat AMR with updated and novel perspectives.

References

• Rørtveit, G. and Simonsen, G. (2020) The Primary Care Perspective on the Norwegian National Strategy against Antimicrobial Resistance. Antibiotics 9 (9): 622. Available at: doi.org/10.3390/antibiotics9090622
• Simonsen GS, Berdal JE, Grave K, Hauge K, Juvet LK, Lunestad BT, Riisberg I, Rørtveit G, Urdahl AM, Årdal C. Antibiotikaresistens – Kunnskapshull, utfordringer og aktuelle tiltak. Status 2020. Rapport 2020. Oslo: Folkehelseinstituttet, 2020.

Research Objectives

Professor Guri Rørtveit re-frames AMR under the paradigm of two philosophical concepts, urging a contemporary approach to traditional ideas.

Collaborators

Årstadveien 17, 5018 Bergen, Norway

Bio

Guri Rørtveit is a medical doctor and professor of general practice at the University of Bergen, Norway. Her research focuses on infections in primary care, including outbreaks. She is part of a national expert group on antibiotic resistance appointed by the Norwegian government. The group delivered their report in 2020.

Contact
Årstadveien 17, 5018 Bergen, Norway

E: [email protected]
T: +4799232769
T: +4755586141

Tackling anti-microbial resistance: Updated ways to approach an intractable problem