“It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them…The time may come when penicillin can be bought by anyone in the shops…” — Alexander Fleming, 1945
In my original letter, “A Future Without Antibiotics: How a New Breakthrough Could Save Us from Collapse”, I argued that antibiotics aren’t simply medical tools but are one of the bedrocks of modern civilization. We rely on them for treating infections, as well as enabling safe surgery, childbirth, cancer therapy, organ transplants, industrial food production, and even emergency trauma care. If antibiotics lose efficacy at scale, the consequences cascade far beyond healthcare, shifting the very assumptions of risk management, supply chains, and mortality profiling.
Recently, a new warning from the World Health Organization (WHO) has elevated that scenario from speculative to immediate. On 13 October 2025, the WHO released its Global Antibiotic Resistance Surveillance Report, showing that one in six laboratory-confirmed bacterial infections worldwide in 2023 were resistant to common antibiotic treatments, and that resistance rose in over 40% of pathogen–antibiotic combinations between 2018 and 2023.
And so, the argument on the potential “collapse of antibiotic infrastructure” is now clearly underway.
Today’s letter offers an updated synthesis, expanding on what the WHO numbers add, key shifts in innovation, policy, and systems, what remains missing, and a roadmap for rebuilding or safeguarding this civilizational infrastructure.
What the New WHO Report Adds
1) Quantification of scale and speed.
In my prior piece, I emphasized “if antibiotics become ineffective.” The new WHO data show the scenario is no longer if but already. The data: 1 in 6 infections globally were drug-resistant in 2023; resistance increased in >40% of pathogen–antibiotic pairs since 2018. Coverage by The Guardian underscores the same trend and notes, in particular, severe hospital-borne resistance.
Regional disparities are stark: in the South-East Asia and Eastern Mediterranean regions, roughly 1 in 3 infections are resistant; in Africa, about 1 in 5, with Gram-negative resistance (e.g., E. coli, Klebsiella) to first-line therapies already above 40% globally and >70% in some African settings.
These numbers illustrate that antibiotic effectiveness is eroding globally, and quickly.
2) Geographical inequality and system fragility.
The report underscores that the worst outcomes are in places with weaker health systems: fewer diagnostics, weaker infection prevention, limited access to second-line drugs, and poorer sanitation. Crucially, many of the countries facing the largest challenges lack surveillance capacity to even assess their AMR situation. That means we’re flying partially blind in the places most at risk.
The interplay of weak health systems × weak antibiotic pipeline × higher resistance burden creates a “perfect storm” in many low and middle-income countries, but the ripple effects are global: travel, migration, trade, and agricultural exports ensure no region is truly insulated.
3) Pipeline gap and the narrowing “treatment horizon”.
Perhaps the most sobering reality is that innovation is not keeping pace. Experts quoted in the press note that the toughest Gram-negative infections are outpacing development pipelines, which are dominated by incremental derivatives rather than novel modalities.
4) One-Health reality.
The WHO reiterates that AMR is not just a human-medicine problem but an ecosystem problem spanning human health, animal health, agriculture, and the environment (e.g., antibiotic runoff). Coordinated surveillance and interventions across sectors are essential.
What’s Changed Since the Original Letter
1) Elevated political recognition.
The “one in six” figure has finally entered public discourse, nudging AMR from a scientific concern to a strategic risk. The framing I argued for (treating antibiotic resilience like grid resilience, clean water, or cybersecurity) now feels not only plausible but necessary.
2) Innovation emphasis is shifting.
There’s growing focus on rapid diagnostics, bacteriophages, microbiome modulation, narrow-spectrum agents, and adjuvants that enhance the activity of existing antibiotics. Modeling work on collateral sensitivity - sequencing antibiotics so resistance to one increases sensitivity to another, has matured with actionable design principles for regimen switching.
3) Recognition of human/systemic imperatives.
The problem isn’t just “discover new drugs.” Misuse/overuse, sub-optimal dosing, lack of diagnostics, and environmental leakage all accelerate resistance. Prevention and stewardship are as important as chemistry. The WHO has repeatedly stressed surveillance gaps and the need for better data and governance.
4) The threat is plainly inside the house.
In the U.S., CDC scientists reported a ~70% rise (2019–2023) in infections from so-called “nightmare bacteria,” driven by NDM-producing CRE bugs resistant to nearly all antibiotics. These were once rare and linked to overseas care, but now they’re spreading domestically.
What Still Remains Deeply Missing
1) Incentives for true antibiotic innovation.
Short courses + stewardship (using less, not more) break the volume-based pharma model. We need infrastructure-style economics: subscription/availability payments, market-entry rewards, and delinkage from volume (the WHO and global AMR advocates have pushed variants of this, but implementation lags).
2) Diagnostics at scale.
Without point-of-care tools to distinguish bacterial from viral infections and identify resistance markers, clinicians prescribe “blindly,” increasing selection pressure. Nearly half of the countries didn’t report to the GLASS report, and surveillance gaps slow rational use.
3) Equitable access.
Low- and middle-income countries are pushed to use last-resort therapies first, often unaffordable or unavailable, turning parts of the world into reservoirs of resistance. Global supply, regulatory capacity, and stewardship networks remain thin.
4) Preventive infrastructure.
Water, sanitation, hygiene, vaccination, and hospital infection control are the first line when antibiotics falter, yet are under-invested in across many health systems. Resistance tracks with weak infection control.
5) Governance that matches the scale.
The 2024 UN AMR declaration was a start, but we still lack a climate-style global governance architecture with measurable commitments, financing, and enforcement.
Rebuilding (or Safeguarding) Antibiotic Infrastructure: A Potential Roadmap
1) Treat antibiotics as civilizational infrastructure.
Reframe antibiotics from “drug class” to infrastructure spanning healthcare, food systems, and societal risk-management. Create a global financing facility to fund R&D, manufacturing surge capacity, and stewardship as public goods; publish an Antibiotic Resilience Index to benchmark nations annually.
2) Build next-gen antimicrobial defenses.
Invest in new broad-spectrum agents but also in: (a) narrow-spectrum/pathogen-specific drugs, (b) adjuvants that restore potency, (c) bacteriophages/lysins/microbiome engineering, and (d) AI + synbio discovery engines. Leaders like MIT’s James Collins have spent years decoding antibiotic action and bacterial defense networks, precisely the kind of systems-biology approach we need to scale.
3) Make diagnostics + stewardship the default layer.
Deploy low-cost point-of-care diagnostics worldwide, and wire them into decision support and real-time surveillance. Use machine learning-guided therapy sequencing to exploit collateral sensitivity and slow resistance evolution, moving from one-off prescriptions to adaptive regimens.
4) Strengthen prevention and system resilience.
Fund water, sanitation, and hygiene, vaccination campaigns, hospital infection-control, and agricultural reforms (ending routine prophylactic use, monitoring runoff). The WHO’s One-Health framework should govern policy across ministries — health, agriculture, and environment.
5) Build governance, financing, and equity mechanisms.
Set up a Global Antibiotic Resilience Fund, scale “subscription” payments (pay for availability, not volume), use pooled procurement to guarantee equitable access to new drugs and diagnostics, and mandate transparent national reporting with independent audits.
Why This Matters for Civilization
1) The hidden infrastructure of low-risk life.
C-sections, hip replacements, chemo, transplants, ICU trauma care, neonatal care —all assume effective antibiotics. As efficacy erodes, the “background risk” of modern medicine rises: more complications, longer stays, higher costs, higher mortality.
2) Global interdependence.
Pathogens don’t respect borders. Misuse or lack of stewardship in one region degrades options everywhere - hence AMR is a global public-goods problem.
3) Time-to-failure is accelerating.
Resistance is rising faster than new therapies are arriving; the half-life of our drugs is shortening. Adaptive regimens and adjuvants can buy time; diagnostics and prevention can reduce pressure, but we have to move now.
4) Equity is a moral and practical imperative.
If collapse hits the weakest systems first and then spreads, we just face a medical crisis, but more importantly, we face a legitimacy crisis for global health. Equitable access is both an ethical and a strategic imperative.
Toward a Future With (or Without) Antibiotics
The future isn’t prewritten, but the window is small, and biology + technology + finance + governance is a nonlinear system. A few scenarios to consider from the report:
1) Optimistic trajectory (“Rebuilt infrastructure”): Diagnostics scale globally; stewardship becomes default; new therapies and adjuvants deploy equitably; efficacy decline slows; we stabilize at a resilient equilibrium.
2) Middle-road (“Managed decline”).
High-income countries improve outcomes; Low and middle-income countries lag; resistance rises regionally; costs and complications increase without global collapse.
3) Pessimistic (“Civilizational rollback”).
Stewardship fails; diagnostics don’t scale; innovation stalls; routine procedures become high-risk; food systems wobble; inequality deepens.
Given the WHO data, we are already on the cusp between 2 and 3 unless action accelerates.
Final Thoughts
The collapse of antibiotic effectiveness is unfolding - it’s no longer a remote scenario. To respond, we have to treat antibiotics less as an afterthought and more as the infrastructure that underwrites low-risk modern life. The blueprint is clear: investment, innovation, diagnostics, prevention, and governance — fully integrated. A narrow-spectrum drug without diagnostics won’t save us, and diagnostics without access and stewardship won’t either. We have to design the system.
With belief,
Yon
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