爱思英语编者按:抗生素(antibiotic)是由微生物(包括细菌、真菌、放线菌属)或高等动植物在生活过程中所产生的具有抗病原体或其它活性的一类次级代谢产物,能干扰其他生活细胞发育功能的化学物质。现临床常用的抗生素有转基因工程菌[1]  培养液液中提取物以及用化学方法合成或半合成的化合物。目前已知天然抗生素不下万种。

Antibiotics
抗生素
When the drugs don't work
当药物无效时
 
How to combat the dangerous rise of antibiotic resistance
如何与危险的抗生素耐药性的增多做斗争
 
May 21st 2016 | From the print edition
 
SOME people describe Darwinian evolution as “only a theory”. Try explaining that to the friends and relatives of the 700,000 people killed each year by drug-resistant infections. Resistance to antimicrobial medicines, such as antibiotics and antimalarials, is caused by the survival of the fittest. Unfortunately, fit microbes mean unfit human beings. Drug-resistance is not only one of the clearest examples of evolution in action, it is also the one with the biggest immediate human cost. And it is getting worse. Stretching today's trends out to 2050, the 700,000 deaths could reach 10m.
 
有人说,达尔文的进化论“不过是一种理论”。那就试着把这种理论给每年死于耐药性感染的700000人的家属和朋友解释一下吧。对抗生素和抗疟疾药等抗菌药的耐药性是由适者生存理论引起的。不幸的是,适应细菌就意味着不适应人类。耐药性不仅是活生生的进化正在进行中的例子之一,还是体现着最大的人类直接代价的例子,而且耐药性正变得越来越严重。把现在的这种趋势拉长到2050年,700000例死亡可能达到10000000例。
 
Cynics might be forgiven for thinking that they have heard this argument before. People have fretted about resistance since antibiotics began being used in large quantities during the late 1940s. Their conclusion that bacterial diseases might again become epidemic as a result has proved false and will remain so. That is because the decline of common 19th-century infections such as tuberculosis and cholera was thanks to better housing, drains and clean water, not penicillin.
 
愤世嫉俗的人可能会因为认为自己以前已经听说过这种说法而得到谅解。人们自抗生素在20世纪40年代后期开始被大量使用以来就一直在抱怨耐药性。他们关于细菌性疾病可能卷土重来的结论已证明是错误的,而且将来也是如此。究其原因。结核病和霍乱等19世纪常见传染病的消退,是因为更好的居住条件和排污系统和清洁的水,而不是青霉素。
 
The real danger is more subtle—but grave nonetheless. The fact that improvements in public health like those the Victorians pioneered should eventually drive down tuberculosis rates in India hardly makes up for the loss of 60,000 newborn children every year to drug-resistant infections. Wherever there is endemic infection, there is resistance to its treatment. This is true in the rich world, too. Drug-resistant versions of organisms such as Staphylococcus aureus are increasing the risk of post-operative infection. The day could come when elective surgery is unwise and organ transplants, which stop rejection with immunosuppression, are downright dangerous. Imagine that everyone in the tropics was vulnerable once again to malaria and that every pin prick could lead to a fatal infection. It is old diseases, not new ones, that need to be feared.
 
真正的危险更加不易觉察——因而更加严重。像维多利亚时代最先带来的那些公共卫生方面的改善最终应当降低印度肺结核发病率这个事实几乎无法弥补每年60000名新生儿死于耐药性感染的损失。只要存在地方性感染,就有对其治疗的耐药性。富裕世界也是如此。金黄色葡萄球菌等微生物的耐药性版本正在提高术后感染的风险。选择性手术是不明智的、利用免疫抑制阻止感染的器官移植是非常危险的日子终将到来。设想一下:在热带地区,如果人人都在面对疟疾再次表现的不堪一击,如果每一次针刺都可能导致致命感染,ji[届时]是那些老病,而不是新病的存,才是最让人害怕的。
 
 
Common failings
常识错误
 
The spread of resistance is an example of the tragedy of the commons; the costs of what is being lost are not seen by the people who are responsible. You keep cattle? Add antibiotics to their feed to enhance growth. The cost in terms of increased resistance is borne by society as a whole. You have a sore throat? Take antibiotics in case it is bacterial. If it is viral, and hence untreatable by drugs, no harm done—except to someone else who later catches a resistant infection.
 
耐药性的传播是常识悲剧的一个例子;正在失去的东西的代价却不被当事方所见。养牛?就把抗生素加到饲料中,以促其生长。日渐增强的耐药性的代价由整个社会来承担。嗓子疼?用抗生素吧,万一要是细菌性的呢;如果是病毒性的,虽说药物治不了,但是没有什么害处——除非是后来得了耐药性感染的其他人。
 
The lack of an incentive to do the right thing is hard to correct. In some health-care systems, doctors are rewarded for writing prescriptions. Patients suffer no immediate harm when they neglect to complete drug courses after their symptoms have cleared up, leaving the most drug-resistant bugs alive. Because many people mistakenly believe that human beings, not bacteria, develop resistance, they do not realise that they are doing anything wrong.
 
做正确的事的动机的缺乏是难以改正的。在某些医疗体系中,医生是有偿开药。病人在症状消失后忽视完成药物疗程时没有承受任何直接伤害,却让最具耐药性的细菌活了下来。由于许多人误以为是人类而不是细菌发展出了耐药性,因而没有意识自己正在做错什么事。
 
If you cannot easily change behaviour, can you create new drugs instead? Perversely, the market fails here, too. Doctors want to save the best drugs for the hardest cases that are resistant to everything else. It makes no sense to prescribe an expensive patented medicine for the sniffles when something that costs cents will do the job.
 
如果不能轻易地改变行为,那能造出新药吗?事与愿违,市场在这方面也很失败。医生希望把最好的药留给对其他药物都有耐药性的疑难杂症。在花少量的钱就能治好的情况下,给感冒流鼻涕这些的常见病开出昂贵的专利药毫无意义。
 
Reserving new drugs for emergencies is sensible public policy. But it keeps sales low, and therefore discourages drug firms from research and development. Artemisinin, a malaria treatment which has replaced earlier therapies to which the parasite became resistant—and which now faces resistance problems itself—was brought to the world not by a Western pharmaceutical company, but by Chinese academics.
 
为急症储备新药是明智的公共政策。但是,这使得销量处于低位,因而不利于制药企业进行研发。青蒿素,这种业已取代了寄生虫已经变得对其有耐药性的早期疗法——且目前自身也面临耐药性问题——的疟疾药,不是由一家西方制药企业,而是由中国专家,带给这个世界的。
 
Sugar the pill
让良药可口
 
Because antimicrobial resistance has no single solution, it must be fought on many fronts. Start with consumption. The use of antibiotics to accelerate growth in farm animals can be banned by agriculture ministries, as it has in the European Union. All the better if governments jointly agree to enforce such rules widely. In both people and animals, policy should be to vaccinate more so as to stop infections before they start. That should appeal to cash-strapped health systems, because prophylaxis is cheaper than treatment. By the same logic, hospitals and other breeding grounds for resistant bugs should prevent infections by practising better hygiene. Governments should educate the public about how antibiotics work and how they can help halt the spread of resistance. Such policies cannot reverse the tragedy of the commons, but they can make it a lot less tragic.
 
由于抗菌药耐药性没有单独的解决方法,它必须在多条战线上遭遇打击。先从用量开始。抗生素之于加速家畜生长的使用可以像在欧盟那样,被农业部门明令禁止。最好是各国政府一致同意大范围地执法。在人和动物方面,政策应当是给更多的对象大预防针,以便在爆发前阻止传染。这对资金紧张的医疗体系应该很有吸引力,因为预防比治疗更便宜。同理,医院和其他的抗药细菌孳生地应当通过践行更好的卫生习惯的方式来阻止传染。政府应当想公众传授抗生素如何发挥作用以及他们怎样做才能帮助阻止耐药性扩散等方面的知识。这些政策不可能逆转常识悲剧,但是能让它们不再那么悲剧。
 
Policy can also sharpen the incentives to innovate. In a declaration in January, 85 pharmaceutical and diagnostic companies pledged to act against drug resistance. The small print reveals that the declaration is, in part, a plea for money. But it also recognises the need for “new commercial models” to encourage innovation by decoupling payments from sales.
 
政策还可以提高奖励以进行创新。今年1月份,85家制药企业和诊断设备企业曾在一份声明中承诺向耐药性开战。声明中的小字表明,这份声明部分是对资金的一项呼吁。但是,它也承认了对于“新商业模式”的需要,以便通过将薪酬与销售想脱钩的方式鼓励创新。
 
That thought is taken up this week in the last of a series of reports commissioned by the British government and the Wellcome Trust, a medical charity. Among the many recommendations from its author, Jim O'Neill, an economist, is the payment of what he calls “market-entry rewards” to firms that shepherd new antibiotics to the point of usability. This would guarantee prizes of $800m-1.3 billion for new drugs, on top of revenues from sales.
 
本周,这种观点在英国政府与医疗慈善机构——惠康基金会发布的系列报告中的最后一篇中被采纳。在这篇论文的作者——经济学家吉姆·奥尼尔所提出的诸多建议中,有一条就是他称之为是对培育新抗生素直至具有可用性的企业的“市场进入大奖”的薪酬。它会保证给予新药8亿—1.3万亿美元的大奖,是最高的销售收入。
 
Another of Lord O'Neill's suggestions is to expand a basic-research fund set up by the British and Chinese governments in order to sponsor the development of cheap diagnostic techniques. If doctors could tell instantaneously whether an infection was viral or bacterial, they would no longer be tempted to administer antibiotics just in case. If they knew which antibiotics would eradicate an infection, they could avoid prescribing a drug that suffers from partial resistance, and thereby limit the further selection of resistant strains.
 
奥尼尔爵士的另一个建议是,扩大由英国政府和中国政府设立的基础研究基金,以便资助廉价诊断技术的开发。如果医生能够立即分辨出一种传染病是病毒性的还是细菌性的,就不再会为使用凑手的抗生素所诱惑。如果它们对哪一种抗生素杀死哪一种传染有了解的话,就能避免开出遭受部分耐药性困扰的药物,因而就能限制抗药链的进一步自然淘汰。
 
Combining policies to accomplish many things at once demands political leadership, but recent global campaigns against HIV/AIDS and malaria show that it is possible. Enough time has been wasted issuing warnings about antibiotic resistance. The moment has come to do something about it.  
 
综合运用这些政策以同时完成许多事情需要政治方面的领导。但是,近年来针对HIV/AIDS和疟疾的全球性运动表明这是可能的。大量的时间都浪费在了发布抗生素耐药性警告上面,积极作为的时刻已经到来。