Challenge Is Doubly Great for the Developing World

Igor Heifetz ・ Princeton Environmental Institute

By the time antibiotics were widely introduced in the 1940s, infectious diseases were already in decline in high-income countries thanks to improvements in sanitation and the introduction of vaccines. In many developing countries, on the other hand, antibiotics were introduced against a backdrop of high infection rates with inadequate water and sanitation, poor vaccination rates and rampant spread of pathogens in hospitals.

Many low- and middle-income nations now face a lack of access to antibiotics as well as common antibiotic overuse due to social norms and expectations. Rising incomes in many parts of the world are putting powerful antibiotics within the reach of a growing number of people, who can buy them from the closest store. In India, antibiotic sales have increased nearly 70 percent between 2005 and 2009. In China, many hospitals rely on pharmaceutical sales for income; one study estimated that a quarter of revenue in two hospitals was derived from antibiotic sales. One can only imagine the incentives this has on antibiotic sales within the hospital.

Resistance is increasing worldwide, but particularly in low- and middle-income countries. An estimated 60,000 children in India die each year before the age of one month of infections caused by drug resistant pathogens. (However, many more children in these countries still die due to lack of access to simple antibiotics than the numbers who die of untreatable infections.)

The paradox is that many people who will die from resistant infections live in low and middle-income countries where antibiotic use was low in the past, in the same way that climate change can disproportionately affect nations that may have done little to cause it.

High-income countries can help by reducing their own use of antibiotics and demonstrate how that is possible without increasing the number of deaths by infectious diseases. Richer countries could also invest more in new drugs and vaccines, which could be available to low-income households in a couple of decades.


There is an urgent need for a global agreement to manage antibiotic effectiveness as a global public good, similar to what has been done for fisheries. Such an agreement would allow for surveillance of drug resistance, greater research into new antibiotics, vaccines, and inexpensive point-of-care diagnostics as well as coordination of policies to improve water, sanitation and public health so that fewer antibiotics are needed. Global co-operation will be essential in facing the growing challenge of antibiotic resistance.