The development of antimicrobial resistance in many pathogenic microbes poses one of
the most serious problems in the control of infectious diseases (1-3).
Antimicrobial resistance results from the ability of microbes to adapt to anthropogenic
pressures; therefore, it is not a passing trend but likely a permanent feature in the
fight against infectious diseases (4). This article highlights the
legal issues involved in addressing the problem of antimicrobial resistance.
Law and Global Public Health
Globalization interferes with infectious disease control at the national level (1,5-7). While microbes move freely around the world, unhindered by
borders, human responses to infectious diseases are conditioned by jurisdictional
boundaries. Therefore, public health responses to infectious diseases must constantly
navigate the mazes created by international and national law. Although national law now
dominates legal approaches to infectious diseases, the global nature of the emerging
infectious disease problem points towards a larger future role for international law.
Especially in federal systems, countries often divide authority for public health among
various levels of government. In the United States, for example, states have primary power
for public health because the Constitution did not grant the federal government explicit
public health powers (8). While the federal government has authority
to act in the public health context (9), its statutes and
regulations derive from other federal powers. Most U.S. public health law is at the state
level. The emerging infectious disease threat points to a larger role not only for
international but also for federal law. Federal agencies create networks that allow the
state and national governments to cooperate on issues such as antimicrobial resistance,
but public health law remains primarily a state domain; therefore, state laws on public
health may need to be reevaluated in the context of emerging infectious disease control (10).
Public Health Strategies to Address Antimicrobial Resistance
The dominant public health strategy against antimicrobial resistance contains improved
surveillance of resistant pathogens, as well as rational use and increased research and
development of new antimicrobial drugs (1). These elements fit
within the larger strategy to address emerging infectious diseases, which stresses
surveillance, applied research, prevention and control, and infrastructure development (1).
Surveillance is critical to the control and prevention of infectious diseases (1). Since no national or global surveillance system exists for
monitoring antibiotic resistance, improved surveillance is a top priority (11). Surveillance is also useful in addressing the threat of biological
weapons and protecting the community from highly contagious infectious diseases. Law is
critical to surveillance not only because reporting information must be a legal duty, but
also because law is needed to deal with the tensions sometimes arising between individual
privacy rights and the community's interest in being protected from infectious diseases.
International and domestic surveillance systems are based on the legal duty to report
certain public health information. The International Health Regulations mandate, for
example, that member states of the World Health Organization (WHO) report outbreaks of
plague, cholera, and yellow fever to WHO (12). Similarly, state
public health departments in the United States legally mandate the reporting of cases of
certain diseases from health-care providers to public health agencies (13).
Existing laws at the international and national level require reporting of a limited
number of diseases, do not require systematic reporting of antimicrobial resistance, and
receive inadequate compliance or noncompliance. WHO, however, has proposed including
surveillance of antimicrobial resistance in the revisions of the International Health
Regulations (14-16) and requiring drug resistance reporting.
In the United States, surveillance of antimicrobial resistance has been described as
woeful (17). In 1992 less than $55,000 was spent on antibiotic
resistance surveillance for human pathogens in the United States at the local, state, and
federal levels combined (11). While the need for improved
surveillance of antimicrobial resistance is recognized (1), state
reporting laws have not changed much. For example, although the Council of State and
Territorial Epidemiologists recommended in 1995 that states make drug-resistant Streptococcus
pneumoniae reportable (18), not all states have (D. Bell, pers.
Several factors explain the lag of state responses to federal recommendations on
resistance surveillance. First, state laws on infectious diseases often do not keep pace
with new scientific findings (10). In addition, many states do not
have within their legal systems the flexibility needed to respond to new threatsas
was the case, for example, when the Council of State and Territorial Epidemiologists
recommended that Escherichia coli O157:H7 be made reportable (13).
Second, adding new surveillance responsibilities is difficult because of inadequate
resources (13). These two factors indicate inadequate emphasis on
public health within many state governments. The structure of public health law in the
United States can, therefore, impede antimicrobial resistance strategies. As at the
international level, if reporting is not required, surveillance for antimicrobial
resistance is compromised.
Changes in diagnostic testing in the United States also raise public health and legal
concerns about surveillance. Privatization of laboratory services by state legislatures
may compromise national surveillance of emerging infectious diseases and investigation of
outbreaks because many surveillance systems rely on data from state laboratories (13). In addition, because of economic pressures, hospitals increasingly
rely on testing done in areas outside their jurisdiction; therefore, accurate information
on infectious diseases in their areas may not be available. Diagnostic testing done by
private laboratories may require closer federal regulation to protect the quality of
needed surveillance data (D. Bell, pers. comm.).
Creation of a legal duty does not ensure the success of a policy. WHO member states
have routinely ignored required outbreak reporting of plague, cholera, and yellow fever (4,19,20). Reporting of diseases within U.S. states
is sometimes poor, haphazard, and unhelpful (21). Fulfillment of
legal duties often hinges on sufficient resources. In many developing countries public
health systems may be inadequate (22). Thus, financial and technical
leadership is needed from national governments towards local authorities and from
international organizations towards developing countries. In addition to legal
requirements, national regulatory barriers may also hinder global surveillance. Such
surveillance will require many countries to import and use equipment, software, and
reagents to detect and report on antimicrobial resistance. Eliminating barriers could
improve prospects for global surveillance. A precedent can be found in the proposed
Convention on the Provision of Telecommunication Resources for Disaster Mitigation and
Relief Operations, which obligates the parties, where possible, to lower or remove
regulatory barriers for using telecommunication resources during disasters (23).
Surveillance systems sometimes have to balance the privacy of the patient with the need
for useful scientific and medical information and the need of the community to be
protected from the spread of infectious diseases (9). As the
HIV/AIDS epidemic has demonstrated, the privacy issue is particularly acute in sexually
transmitted diseases. Because in some sexually transmitted diseases, e.g., gonorrhea, the
infectious organisms are developing resistance to antibiotics, the inherent privacy
concerns are compounded by surveillance-related privacy concerns. Increased surveillance
for antimicrobial resistance may heighten privacy concerns with respect to other diseases,
such as multidrug-resistant tuberculosis (MDRTB).
Different systems of law deal with privacy concerns differently, which could create
legal problems for global surveillance of antimicrobial resistance. The differences
between U.S. and European Union policies illustrate this difficulty. In the United States,
the privacy of health-related information is of concern. Health information gathered by
public health agencies is regulated largely by the Constitution and by state statutes.
While the Constitution "requires reasonable levels of privacy and security when the
government collects personally identifiable data through . . . disease reporting" (9), a recent survey of U.S. state legislation on public health
information privacy concluded that many states' safeguards of public health privacy are
insufficient (24). Laws protecting private sector records are even
weaker (9). Some states regulate private dissemination of
health-related information through physician-licensing systems, common-law tort rules on
invasion of privacy, or statutes (25). Nevertheless, such legal
regulations may not adequately protect privacy, as health-related information is
increasingly manipulated electronically by health-care providers, health maintenance
organizations, and insurance companies (9). Lack of laws adequately
protecting the privacy of health-care information has led to calls for federal regulation
(9,25,26), and some legislative proposals have
been introduced in Congress (27).
The European Union has a strict law forbidding the processing of health information
data without the written permission of the patient (28). This law
places other strict conditions on the use of health data directly affecting European Union
surveillance efforts. The contrast between American and European legal protection for
health-related information may affect global surveillance efforts because European law
permits states to withhold personal data from those who cannot adequately protect these
A particularly important development is the growth of privately owned infectious
disease information. Private initiatives are building global information-sharing networks
on various disease issues through the Internet and other information technologies (4,29,30); private companies are starting to
monitor and test bacterial resistance globally (31); and some
for-profit companies gather and sell epidemiologically useful information. These private
efforts raise legal questions: privacy issues arise with the dissemination of
epidemiologic data by private companies; this dissemination is treated differently in
different countries; jurisdictional problems arise regarding legal regulation of
information sharing in cyberspace (32) (the quality of health
information on the Internet, for example, is being questioned [33-35]);
and legal (and ethical) concerns arise with the practice of selling epidemiologic data,
especially with data gathering, and whether governments can compel disclosure of privately
gathered information in the interest of public health.
While most of the pathogenic agents considered to be the most likely candidates for use
as biological weapons do not exhibit resistance (36), the potential
use of resistant pathogens as weapons is of concern because resistance blunts one of the
few lines of defense against a biological weapons attack. For the U.S. Department of
Defense, antibiotic resistance is one of the criteria for characterizing suspicious
outbreaks of infectious disease that might point to a possible biological weapons event (37).
The main source of international law on biological weapons, the 1972 Biological Weapons
Convention, prohibits the development, production, and stockpiling of biological and toxin
weapons (38). Negotiations are under way to strengthen the Biological
Weapons Convention through a protocol that both establishes compliance procedures and
commits states to improving domestic and global surveillance of infectious diseases (37). Calls for reform are also being made in domestic legal systems (37). The comprehensive statutory and regulatory system in the United
States that governs the acquisition, use, and transfer of biological agents that pose a
threat to public health (39) might serve as a model for legislation
in other countries.
Personal Control Measures
The authority of public health officials to detain or isolate persons infected with
highly contagious and resistant pathogens in order to protect the community is another
important legal issue. MDRTB, for example, is a threat to public health because it is
highly infectious (10). To deal with its TB epidemic, New York City
has issued dozens of orders to detain MDRTB patients for isolation and compulsory
treatment (40). Controversy exists about the proper scope of
detaining patients for infectious disease control purposes (13).
While U.S. courts have upheld detaining infected patients to protect public health (41), governments today face heightened judicial scrutiny of personal
control measures in the public health context (10,42).
In one case in New Jersey, the court held that public health authorities, in applying a
1912 TB control statute, had to comply with contemporary notions of due process and the
Americans with Disabilities Act in order to detain and isolate a patient with MDRTB (43). At a time when antimicrobial resistance may have created a greater
need for personal control measures for public health (e.g., with MDRTB), the status of
U.S. law on the scope and nature of the government's power to undertake such measures
seems unsettled (13). U.S. public health law may need to be modified
to allow public health officials to control demonstrated threats of risk through flexible
policy options that minimize infringements on individual rights (10).
The proper scope of personal control measures may appear pertinent only to
industrialized countries, given that only those countries can identify resistant pathogens
and their human hosts. In addition, the notion of personal control measures against
drug-resistant malaria patients in Africa seems far-fetched, given the scale of the
problem. Nevertheless, the importance of international human rights law to effective
public health policiesas seen in the context of HIV/AIDS (44)demonstrates
that complacency towards individual rights in any public health policy is dangerous
legally and medically.
Rational Use of Antimicrobial Drugs
Antimicrobial drug misuse in both industrialized and developing countries
is a problem in connection not only with human treatment, but also with food production (11,45,46). More rational use of antimicrobial
drugs in every countryfor disease treatment and food productionmust be at the
core of the response to antimicrobial resistance.
Education has been suggested as the primary tactic for improving antimicrobial drug use
(1,16). WHO has recommended "a code of
practice for prudent use of antimicrobials in food animal production" (47).
However, the global scope of antimicrobial resistance indicates that an integrated
strategy operating at both the national and international legal levels is needed. Such an
integrated strategy faces political and legal challenges. Building effective national
legal regimes regarding prudent antimicrobial use in many developing countries is
unrealistic absent financial, political, and legal support from the international
community (46). International legal harmonization of principles for
prudent antimicrobial drug use will have to include monitoring and enforcement, as well as
financial, technical, and legal assistance by industrialized countries to developing
The international legal strategy needed will be difficult to create. WHO's limited
powers to adopt regulations (48) do not seem to extend to creating
regulations regarding the use of drugs. WHO has not, for example, proposed revising the
International Health Regulations to rationalize the use of antimicrobial drugs. WHO has
authority to adopt a convention on the use of antimicrobial drugs (49),
but it has not done so (4). As illustrated by its proposal for a
code of practice, rather than regulations, for antimicrobial use in food animal
production, WHO historically has preferred not to use international legal powers to
advance global health. Lessons from international environmental efforts suggest that
international law must play a major role in setting international standards for
implementation domestically and creating the political, technical, and financial
conditions necessary to integrate international and national law (19).
The misuse of antibiotics in food production also raises concerns under international
trade law. If antimicrobial drugs routinely used by food producers lose their
effectiveness against animal-borne or plant-borne diseases, exports of contaminated food
may be restricted by countries applying sanitary and phytosanitary measures (SPS measures)
under the World Trade Organization (WTO) and other international trade agreements to keep
such food out of their territories as threats to human, animal, or plant health (50). In addition, exports might be disrupted by countries applying SPS
measures under international trade agreements against products suspected of containing
harmful residues of antimicrobial drugs. The Codex Alimentarius Commission already sets
standards for residues from veterinary drugs in food through its Committee on Residues of
Veterinary Drugs in Foods, and WHO has recommended that this Codex committee discuss
antimicrobial resistance (47). Codex standards have become important
in international trade law through the WTO Agreement on the Application of Sanitary and
Phytosanitary Measures (SPS Agreement) (50), which uses these
standards as a basis for international harmonization of SPS measures. The importance of
Codex food safety standards to international trade law was seen in the Beef Hormones Case,
in which the WTO held that the European Union violated the SPS Agreement for not providing
scientific justification for a beef hormone regulation stricter than the relevant Codex
The inability of many governments to regulate antimicrobial drug use and the consequent
misuse of these drugs raise the possibility that countries might use trade restrictions on
food produced with improper use of antimicrobial drugs. In this situation, the food
products might have residue levels below those established as maximums by Codex, but the
trade restriction is intended to pressure the exporting country to improve regulation of
antimicrobial drug use and the process by which the product is made. In the context of
environmental protection, trade restrictions seeking to change a production process in
another country, rather than to protect against health dangers from a particular product,
have been ruled incompatible with international trade law (54-56).
Although "relevant processes and production methods" (SPS Agreement, art. 5.2)
form part of a risk assessment under the SPS Agreement, the risk must be a specific health
risk from the product (e.g., highly inconsistent residue levels created by inadequate
antimicrobial regulation) rather than fear of the health consequences of antimicrobial
misuse. To avoid losing trade restrictions as part of a general strategy to combat
antimicrobial misuse, legitimate trade restrictions against countries that systematically
neglect recognized principles and practices for antimicrobial use might be considered;
such a move would elevate the status of Codex's Code of Practice for Control of the Use of
Veterinary Drugs and Guidelines for the Establishment of a Regulatory Programme for
Control of Veterinary Drug Residues in Foods, as the SPS Agreement has elevated the
importance of Codex's Maximum Residue Levels for Veterinary Drugs in Foods.
The International Conference on Harmonization, a multilateral effort between the United
States, Japan, and the European Union to harmonize pharmaceutical regulatory systems, is
another forum for discussing antimicrobial drug resistance. If national regulatory systems
begin to grapple with the overuse of antimicrobial drugs, the International Conference on
Harmonization might provide a forum to discuss a harmonized approach to more rational drug
use in the United States, Japan, and the European Union. As structured, the Conference
does not include other countries where overuse of antimicrobial drugs is a serious
National laws for improving antimicrobial drug use face difficulties in industrialized
countries; realistic national strategies confront legal and political hurdles. In the
United States, state legislatures probably have the power to regulate how physicians
prescribe antimicrobial drugs, but any attempt to legislate more rational use of drugs
might evoke negative reactions from physicians and their medical associations, who might
oppose the government's efforts to interfere with their professional judgment (57). If formal legislative regulation would not prove feasible, an
alternative would be self-regulation by the medical and veterinary professions through
practice guidelines, for example (57). A peer review process to
monitor antimicrobial drug use has also been recommended (1).
Managed care organizations may be included in the effort to control misuse of
antimicrobial drugs, given their power and economic incentives to curb such misuse by
Formal regulation of antimicrobial use may be needed, which would involve monitoring
and enforcement. In the United States, Congress could regulate use of antimicrobial drugs
by monitoring interstate commerce in these products. Congress probably does not have the
authority to regulate antimicrobial prescription practices directly; such authority rests
with the states. The U.S. Food and Drug Administration (FDA) has authority to restrict the
postapproval marketing of new drugs designed for treating serious or life-threatening
illnesses and has indicated that these regulations can be used specifically in cases of
new antimicrobial drugs (17,58). Restricted
distribution is, however, a disincentive to the development of new drugs, and the
regulations do not address misuse of existing products. Another regulatory strategy
available to the FDA for dealing with resistance in existing products is to modify
labeling requirements; modifying labels is, however, somewhat cumbersome (17).
Effective regulatory changes in the United States will be jeopardized by the lack of
similar changes in other countries.
Perhaps the most powerful U.S. federal strategy would be to make implementation of
state policies to curb the misuse of antimicrobial drugs mandatory before states receive
federal funds earmarked for public health. Although states might argue that this would
encroach on their traditional public health rights and powers, such a federal enactment
would be constitutional. In addition, using federal funds to improve antimicrobial use
policies nationwide fits with the need for federal political leadership as well as
financial and technical assistance. State governments might, therefore, welcome federal
money conditioned on implementing policies the money supports. Pharmaceutical companies,
worried about the federalization of policies affecting their economic relationships with
local and state health-care providers, might oppose these mandates. In addition, federal
leadership in this way would also run counter to trends in other areas, such as welfare
reform, which are moving responsibilities from the federal to the state level.
In countries where governments subsidize the purchase of antimicrobial drugs,
legislative or regulatory changes in these subsidies could lead to a decline in the use of
the drugs. When Iceland ended government subsidies of antimicrobial drugs, their use in
Iceland declined, while sales kept increasing in other Nordic countries (59).
Although Iceland's legislative change was made for political, not medical reasons (59), it illustrates the possible impact of legislative and regulatory
controls on the use of antimicrobial drugs.
Improving physicians' awareness of antimicrobial resistance does not address, however,
misuse of these drugs by patients (60). MDRTB has developed largely
because of improper adherence by patients to TB therapy (10);
directly observed therapy was initiated as a result. Because patient misuse of
antimicrobial drugs also contributes to the public health crisis, proper completion of
antimicrobial therapy must also be addressed.
New Antimicrobial Drug Research and Development (R&D)
As the antimicrobial arsenal shrinks, new drug R&D becomes critical (1). Legislation at the domestic level would ensure adequate funding for
public sector involvement. For diseases that pose an especially large or complex problem
(e.g., malaria), international law can play a role by structuring international
cooperation through such institutions as WHO or the World Bank. The recently proposed
Multilateral Initiative on Malaria, an international multiagency malaria control program,
involves, for example, plans to coordinate R&D on antimalarial products supported by
WHO and the World Bank (61-63).
While public involvement and funds are important, the real engine of pharmaceutical
development is the private sector. However, pharmaceutical companies have only recently
brought new antimicrobial drugs forward for regulatory approval. Critical disincentives
continue to constrain private R&D investment in new drugs: intellectual property
protection, regulatory approval procedures, and perceived antitrust law limitations on
Intellectual Property Protection
Pharmaceutical companies fear that their R&D efforts can be undermined by loss of
intellectual property rights. Lack of secure patents deters pharmaceutical companies from
some R&D activities on new drugs. While the WTO Agreement on Trade-Related Aspects of
Intellectual Property Rights offers pharmaceutical companies better international legal
rules on patent protection (64), the loss of patented agents remains
a concern. Many WTO member states, especially in developing countries, have to upgrade
their national laws to fulfill the agreement obligations, a process that could take years.
International law on intellectual property protection is, thus, a critical piece of the
overall strategy against antimicrobial resistance.
Other patent issues are relevant to the problem of antimicrobial resistance.
Pharmaceutical companies that developed antibiotics years ago but never commercially
exploited them might pursue more antimicrobial R&D if their earlier antibiotics (now
without patent protection) were given extra legal protection, either under patent law or a
legal regime like the Orphan Drug Act (17). The efficacy of such
legal strategies depends, of course, on the number of promising antibiotics potentially in
the R&D pipeline.
Regulatory Approval Procedures
Another legal deterrent to antimicrobial development is the varied, complex, and costly
regulatory approval procedures pharmaceutical companies face in the United States and
other countries. Unilateral efforts are being made in the United States and the European
Union to streamline drug approval regimes, and the International Conference on
Harmonization represents an international effort at harmonization.
Another approach involves creating "expedited approval of new antimicrobials"
(1). FDA, which has already created accelerated approval rules for
drugs that treat serious or life-threatening illnesses, has indicated that these rules
could be used to review new antibiotic treatments (17).
Antitrust Law Limitations on Collaborative R&D
In some circumstances, collaborative R&D efforts by a number of pharmaceutical
companies might be indicated. Pharmaceutical companies have, however, noted the
difficulties that antitrust laws create for collaborative R&D efforts. For example, in
response to calls for collaborative R&D on antimalarial drugs, pharmaceutical
companies are concerned about sharing intellectual property and about laws against cartels
(65). Both U.S. antitrust law and European Union competition law,
however, permit collaboration in certain areas (66,67).
The Inter-Company Collaboration for AIDS Drug Development and the developing Multilateral
Initiative on Malaria set precedents and might be replicated in the area of antimicrobial
Strategies to address antimicrobial resistance as a public health and legal challenge
must consider three levels of interdependence: among the antimicrobial drug surveillance,
use, and R&D components of the public health strategy; among the levels of
lawnational and international; and between the public health and legal aspects of
dealing with antimicrobial resistance.
Each element of the public health strategy against antimicrobial resistance affects and
depends on the other elements. More rational use of antimicrobial drugs and increased
R&D depend on accurate surveillance. Limitations on the use of new drugs negatively
affect the incentives pharmaceutical companies have to develop new drugs. Continued misuse
of antimicrobial drugs places more pressure on both surveillance and new R&D. The
effectiveness of new drugs will have to be measured by accurate surveillance and will
continue to be undercut by their misuse. The lack of new R&D will force continued use
of existing products, reducing their effective life-span. Thus, any public health strategy
addressing antimicrobial resistance must consider all three components.
Because antimicrobial resistance is a global problem, national legal reforms taken in
one or a few countries would suffer if other countries did not take similar actions. For
example, since drug-resistant pathogens travel easily in today's world, national legal
reforms to rationalize antimicrobial use in a few countries might be subverted if such
misuse is not curtailed in many other countries. The creation of new international legal
duties would likewise be undermined if such duties were not translated into national law.
Thus, any legal strategy against antimicrobial resistance must be pursued at both the
national and international levels.
Achieving the public health objectives of an antimicrobial resistance strategy
involves, at each stage, legal considerations and often calls for legal decisions.
National and international law are integral to the public health mission in every country;
the interdependence of public health and law forms part of the large multidisciplinary
challenge created by the global problem of emerging infectious diseases.
Confronting antimicrobial resistance requires not only a scientific and public health
strategy but also a legal strategy. Including law in the developing discourse will broaden
and strengthen the strategy for combating antimicrobial resistance.
An earlier draft of this article was originally presented as a working paper to the
Institute of Medicine's Forum on Emerging Infections in July 1997. Research for this
article was supported by a research grant from the Indiana University School of
Address for correspondence: David P. Fidler, Indiana University School of Law, 211
South Indiana Avenue, Bloomington, IN 47405-1001, USA; fax: 812-855-0555; e-mail: email@example.com.
Mr. Fidler is an associate professor of law at Indiana University School of
Law-Bloomington, where he teaches public and private international law. Mr. Fidler is at
work on a book entitled International Law and Infectious Diseases, to be published by
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