In the book The Rise and Fall of Modern Medicine by James Fanu, published in 1999, the author describes 10 defining discoveries of the modern medical area. They’re all relatively recent moments, none of them happening more than a hundred years ago. The first discovery, not surprisingly, is of penicillin by Alexander Fleming in 1928 and its first use in clinical medicine in 1941.
Fleming and those who took his discovery into clinical practice were surely deserving of the Nobel Prize they were awarded in 1945. The dawn of the antibiotic era meant that diseases that previously had frequently been fatal would henceforth be moved into the column of diseases that doctors could predictably cure.
This discovery, one of the greatest in the history of medicine, is now looking ever more like a spent force, however. Our generation may live to experience the end of the antibiotic era within 100 years of its beginning.
The Demise of Antibiotics?
The reason for the concern regarding antibiotics is partly to be found in their constitution and the way they relate to each other. A bacterium that’s sensitive to antibiotics can undergo a mutation of its genome to become resistant without any outside help. If it doesn’t, there’s plenty of outside help available in the microflora to achieve resistance. Packets of easily moveable genetic material that we call plasmids can be shared by resistant bacteria with bacteria that used to be susceptible to the antibiotic. Such capabilities are also found in transposons, a simpler form of packaging. Once these capabilities are shared around, formerly sensitive bacteria become resistant to the onslaught of antibiotics. They’re armed for battle.
Equally important, perhaps, and as a more recent discovery, is the fact that a host of bacteria in nature are already resistant to antibiotics and may have been for millennia, quite apart from antibiotic exposure. When a population of bacteria within which such bacteria exist is exposed to antibiotics, the antibiotic will kill all the sensitive members of the population and leave all the resistant variants untouched and ready to fill the space. This means that all use of antibiotics must be understood in ecological terms and that any use promotes resistance. The “fittest” bacteria survive to rule the day. The more antibiotics we use, the greater the selection pressure toward ever-more resistant microorganisms.
Let us take the well-known and highly pathogenic Gram-positive bacterium Staphylococcus aureus as an example. This was the bacteria that was killed by the penicillin mold in Fleming’s laboratory, and it was also the agent infecting the patient that first received penicillin in 1941. Sadly, however, it did not take long for resistance to emerge. Already in the 1950s, Staph aureus was beginning to show resistance to penicillin. Scientists countered the trend by making semisynthetic penicillins that would not be rendered ineffective by the bacteria’s resistance mechanisms. The first member of this class was Methicillin.
But nature would not be outfoxed.
Already in the 1970s the term MRSA began appearing: bacteria resistant to Methicillin. Resistance was rare at first, but it rapidly gained momentum. Again, scientists struck back, deploying Vancomycin to subdue the recalcitrant staphylococci. As expected, however, the bacteria struck back again.
Vancomycin-resistant enterococci came on the scene in 1997, and in 2002 the first cases of Vancomycin-resistant staphylococci were reported.
Enterococci hold particular interest in the present context. They are much less pathogenic than staphylococci, but they’re also much more ubiquitous. The digestive system of humans and animals are full of enterococci, by one estimate 106 to 107 in the human intestine, or as many as one million per gram of human feces. These bacteria are virtual laboratories for the development of resistance capabilities and for distributing these capabilities into the ecosystem for the benefit of bacterial brothers and sisters under siege. At the beginning, Vancomycin was developed to combat resistance among enterococci.
The progression of development of resistance has been rapid and dramatic. The same problem has developed among E. Coli and other Gram-negative enteric microorganisms even though multi-resistant S. aureus still top the list of concerns in the hospital setting.
Bacteria and antibiotics are locked in battle at all the critical points designed to ensure bacterial survival—the cell wall (beta-lactams, glycopeptides), DNA-synthesis (quinolones), RNA-synthesis, protein synthesis (macrolides, tetracycline, aminoglycosides), and antimetabolites (trim-sulfa). The bacteria defend themselves by breaking down the antibiotic, by pumping it back out, or by altering enzyme systems that bypass the antibiotic. The result, as we have seen already, is the acquisition of antibiotic resistance. The biological model for transfer of resistance has been verified in vivo.
Resistance as an Ecologic Process
What we see, therefore, and what is even now not fully realized, is that all use of antibiotics contributes to resistance. Development of resistance must be understood as an ecologic process and not only as something that happens in the hospital at the bedside.
Indeed, the reality of interdependence between human and nonhuman beings is particularly striking in the realm of antibiotic resistance. Humans and animals inhabit the same ecologic space. We share each other’s bacteria. E. coli and other bacteria can be traced in the ecosystem from humans to animals and back. We’re in this together. What happens in human medicine will have repercussions for other species. What happens in animal medicine will affect us—and affect us more significantly.
Antibiotic resistance is more than a crisis in modern medicine. It is also—profoundly—an ecologic problem rooted in changing patterns of food production. These patterns, as I will try to show, are raising unprecedented ethical issues.
The Rise of the Factory Farm and Increased Food Consumption
To understand the scope of this problem we need to gain a passing awareness of the rise of the modern factory farm. Western industrialized nations, led by the United States, are undergoing a rapid process of un-settling. Even though the population is growing, fewer hands are needed to produce food. The farmer who in 1960 could feed 25 people is now feeding 130 people. Two percent of U.S. farms produce one half of U.S. agricultural products. Sixty percent of the pork that comes to the market in the U.S. is produced by four firms. This means that farms are getting bigger. We have transitioned from the family farm to the factory farm.
Meat consumption continues to rise despite the huge ecological cost of producing it. It’s high in all industrialized countries but is highest in the United States. By comparison, if we imagine that countries such as Bangladesh and India consume meat at ecologically responsible levels, we get an idea of the task we face in Western countries. The numbers are staggering: for the U.S., 264 pounds of meat per person per year in the year 2020; for Bangladesh, 6.8 pounds per person. (And I’m not even going to address here the other staggering environmental costs of this trend to our resources and environmental pollution).
We see increasing consumption matched against a staggering decline in the number of farms involved in the production chain, most recently with respect to pork. The decline has been precipitous, from 650,000 in 1979 to some 65,000 in 2008. We have indeed moved from the family farm to the factory farm. And we have a new relationship between the farmer and their farm. Acreage is expanding, while the number of farm units has declined to 1850 levels.
“So what?” you might ask. “Why bring this up in a talk on antibiotic resistance?”
Because the amount of antibiotics used in nonhuman medicine is much greater than human use. Estimates of annual antibiotic production show vastly increasing amounts of antibiotics entering the ecosystem, from 0.9 million pounds in 1950 to 44.3 million pounds in 1986 and increasing. Data from the year 2000 show that total human use amounts to about 3 million pounds, all therapeutic, but this is no more than 30 percent of the total of the antibiotics used. The animal data are estimates of annual use in the late 1990s as calculated by the Union of Concerned Scientists and more recently by the U.S. Food and Drug Administration.
The four most important things to notice are (1) the quantity used is much larger in animal use, a ratio of more than 10 to one; (2) we’re talking about non-therapeutic use in animal medicine; (3) we’re talking about sub-therapeutic use; and (4) we’re not talking about use in individual animals but in herds.
Total use of antibiotics has risen dramatically in the poultry industry. Much of this increase owes to more use of tetracycline, which should not reassure anybody because tetracycline is a broad-spectrum antibiotic with a strong tendency to give resistance. Non-therapeutic use means that the animal isn’t sick. Antibiotics are used as growth-enhancers as well as to prevent disease, and therefore dispensed to the entire herd. UCS estimates of human compared to nonhuman use in millions of pounds is only half the story. The other half is that the ecologic shadow of nonhuman use is vastly greater than the numbers alone can convey.
And There’s More
First, let’s explore data that suggests what is not likely to be the solution.
Pharmaceutical science has barely kept ahead of the problem, despite its valiant effort. It’s not possible to stay ahead because we don’t have significant new classes of antibiotics. By now, too, we know that resistance will come almost no matter what we do.
Research and development of new drugs has declined steadily because it’s costly, and it is “unattractive” to develop a drug that by definition should be used sparingly. The money is being spent, instead, on the array of drugs often referred to as “lifestyle drugs” (cholesterol-lowering medications, antihypertensives, drugs blocking acid reflux, and antidepressants).
Factory farming and antibiotic resistance also have an ethical dimension that’s underexposed and unrecognized. Industrialized methods of meat production are disease producing. Crowding is disease producing for humans; it’s no less so for animals. Production methods are impossible apart from extensive use of antibacterial substances. Humans and animals inhabit the same ecologic space. The enteric environment is a nearly perfect environment for the development of new resistance capabilities. Kellogg Schwab, director of the Johns Hopkins Center for Water and Health, said in Johns Hopkins Magazine that “if he tried, he could not build a better incubator for resistant pathogens than the factory farm.” But these, in my view, are lesser concerns.
The greater concern is the ethics of food production, brought to light in poignant and painful detail in Matthew Scully’s book Dominon: The Power of Man, the Suffering of Animals, and the Call to Mercy. The data he brings to the reader in this book tells of a reality that has never before in history been the lot of animals.
“About 80 million of the 95 million hogs slaughtered each year in America, according to the National Pork Producers Council, are intensively reared in mass-confinement farms, never once in their time on earth feeling soil or sunshine.”
It is the ethics of this situation even more than the looming reality of antibiotic resistance that calls us to be aroused. The new reality is not that the animal is slaughtered at the end of its life; it’s that the animal is slaughtered without having lived its animal life.
“Genetically designed by machines, inseminated by machines, fed by machines, monitored, herded, electrocuted, stabbed, cleaned, cut, and packaged by machines—themselves treated like machines ‘from birth to bacon’—these creatures, when eaten, have hardly ever been touched by human hands.”
This is a new reality, a cruel and purely predatory reality. The ecologic consequences are not to be winked at, but the ethical problem is greater because it is so cruel.
“We keep walking. Sores, tumors, cysts, bruises, torn ears, swollen legs everywhere. Roaring, groaning, tail biting . . . frenzied chewing on bars and chains . . . stereotypical rooting and nest building with imaginary straw.”
The ethical problem is greater, too, because it’s so refined and clinical; so scientific and dignified; so purposive and systematic. Scully sees stress written all over the tightly confined animals, but above all he sees despair.
“When they have conquered ‘the stress gene,’ maybe the Ph.D.’s and the guys in white coats can find us a cure for the despair gene, too.”
We’re not mainly talking about killing or vegetarianism or risk factors to health. We’re talking about good and evil playing out in the realm of free-market food production, here brought to our attention by no less a figure than a former speechwriter of George W. Bush.
“Factory farming isn’t just killing. It is negation, a complete denial of the animal as a living being with his or her own needs and nature. It is not the worst evil we can do, but it is the worst evil we can do to them.”
A Biblical Mandate
We have stark choices before us, and an opportunity to see health in a wider perspective—ecological, to be sure, but also ethical; ethical, to be sure, but also theological.
Factory farming is also a matter of what we might call ecotheology; it’s proof of profound narratival loss. The following text is from the most enticing narrative of the beginning of creaturely existence:
“Then God said, ‘Let the waters abound with an abundance of living creatures, and let birds fly above the earth across the face of the firmament of the heavens.’ So God created great sea creatures and every living thing that moves, with which the waters abounded, according to their kind, and every winged bird according to its kind. And God saw that it was good” (Genesis 1:20, 21).
This, we all recognize, is a description of the beginning of nonhuman creation. And then, often overlooked, we read this: “And God blessed them, saying, ‘Be fruitful and multiply, and fill the waters in the seas, and let birds multiply on the earth’ ” (verse 22).
This is the first blessing in the most prestigious of ancient texts, a blessing on nonhuman creation, conferring on sentient, nonhuman creation a bill of rights. It’s followed by two more blessings, a threesome of blessings in this ancient text: a blessing on nonhuman creation, a blessing on human creation, and a blessing on all creation. The remarkable similarity in wording should not be missed:
“God blessed them, and God said to them, ‘Be fruitful and multiply, and fill the earth and subdue it; and have dominion over the fish of the sea and over the birds of the air and over every living thing that moves upon the earth’ ” (verse 28).
“Then God blessed the seventh day and sanctified it, because in it He rested from all His work which God had created and made” (Gen. 2:3).
The blessing on human creation is similar to the blessing on nonhuman creation. We inhabit the same realm of blessing; we are recipients of a similar bill of rights; and we’re bound to each other in a relationship of interdependence. The more extensive blessing on human creation is distinctive mostly for the responsibility it confers on human beings. Moreover, nonhuman creation is not left out of the reckoning and the vision of hope that greets the reader in a more recent text:
“For the creation [and here nonhuman creation is particularly in view] waits with eager longing for the revealing of the children of God; for the creation was subjected to futility, not of its own will but by the will of the one who subjected it, in hope that the creation itself will be set free from its bondage to decay and will obtain the freedom of the glory of the children of God” (Romans 8:19–21).
Nonhuman creation is waiting to be delivered, we read; waiting for sons and daughters of God who understand the theology of blessing and who are not offended by a God who is interested in the well-being of creatures other than ourselves.
Not Just a Bedside Problem
The crisis of antibiotic resistance is not only a bedside problem. It’s an ecological problem that adds a compelling dimension in favor of a nonmeat diet. Those who make this choice can make it for many good reasons of health, but they might also see it as an act of resistance against the predatory and unsustainable treatment of nonhuman creation and the earth.
This choice, significantly, need not be made only because of self-interest in the hour of crisis, in recognition of the consequences that will come to us if we ignore the ecological and ethical violations of modern food production. Better than that, this choice may have a narratival structure, anchored in God’s intent at Creation and all creation’s hope in the eschaton.
Loma Linda University recently celebrated the centennial of its medical school. The person who was indispensable in bringing such an audacious enterprise to fruition, Ellen G. White, was herself a person keenly troubled by the human use of animals for food long before the abuses of factory farming. She wrote copiously on the health advantages of a nonmeat diet before we had evidence-based data to sustain its value. The clincher, however, was a vision of ethics and eco-theology:
“But when the selfishness of taking the life of animals to gratify a perverted taste was presented to me by a Catholic woman, kneeling at my feet, I felt ashamed and distressed. I saw it in a new light, and I said, I will no longer patronize the butchers. I will no longer have the flesh of corpses on my table.”
The Victorian diction notwithstanding, we recognize that the founding mother of Loma Linda University came to see the motivating power of eco-theology, a merciful God acting in a stance of compassion toward nonhuman creatures and inspiring others, in this case a Catholic woman and a Seventh-day Adventist woman, to feel creation’s pain.
Only a few decades after Fleming’s discovery, we’re faced with a crisis of antibiotic resistance, a crisis that uncovers lost awareness of the interdependencies of human existence, a loss of empathy, and a reminder of the poverty that will be ours if we lose contact with the narrative that lies at the foundation for our existence.
There’s a crisis, to be sure, but this crisis is, above all, a call to mercy.
Sigve K. Tonstad is a professor of religion and theological studies in the School of Religion and an assistant professor in the School of Medicine at Loma Linda University in California, United States. He is author of The Lost Meaning of the Seventh Day (Andrews University Press, 2009).
1 Gretchen Kuck and Gary Schnitkey, “An Overview of Meat Consumption in the United States,” farmdocDAILY, University of Illinois Department of Agricultural and Consumer Economics, https://farmdocdaily.illinois.edu/2021/05/an-overview-of-meat-consumption-in-the-united-states.html.
2 Livestock Report 2006, Food and Agriculture Organization of the United Nations, Rome, 2006, https://www.fao.org/3/a0255e/a0255e.pdf.
3 Nathanael Johnson, “Swine of the Times: The Making of the Modern Pig,” Harper’s Magazine, May 2006.
4 Margaret Mellon, Charles Benbrook, and Karen Lutz Benbrook, Hogging It: Estimates of Antimicrobial Use in Livestock (Union of Concerned Scientists, 2001).
5 Dale Keiger, “Farmacology,” Johns Hopkins Magazine online, June 2009, https://pages.jh.edu/jhumag/0609web/farm.html.
6 Matthew Scully, Dominon: The Power of Man, the Suffering of Animals, and the Call to Mercy (New York: St. Martin’s Griffin, 2003).
7 Scully, Dominon: The Power of Man, p. 29.
9 Ibid., p. 268.
11 Ibid., p. 289.
12 Bible texts are from the New King James Version. Copyright © 1979, 1980, 1982 by Thomas Nelson, Inc. Used by permission. All rights reserved.
13 Ellen G. White, Letters and Manuscripts, Vol. 11 (1896), Letter 73a.