One of the most essential tools of modern medicine is at risk. The discovery and use of antibiotics hailed a new era in the treatment of bacterial illnesses. However, the multiplication of antibiotic resistant bacteria that may include multi-antibiotic resistant pathogens (MAR) and their multi-antibiotic resistant genes might be threatening this life saving tool. Scientists have documented the presence of antibiotic resistant bacteria (ARB) and their antibiotic resistant genes (ARG) in the three byproducts of wastewater treatment plants: 1.) biosolids often used as a fertilizer additive on agricultural land; 2.), recycled water used to irrigate leafy green crops consumed raw as well as grass in public parks and other playing fields; and 3.) effluent that is discharged to lakes, rivers, and oceans. The presence of these contaminants should be a call for federal, state, and local policy makers to take action regarding our wastewater treatment plants to reduce the spread of ARBs, their resistant genes, and their water delivery systems.
As physician advocates, we must make the case for redesigning our existing water treatment systems and their water delivery pipe systems in order to continue to protect public health particularly from water borne antibiotic resistant pathogens and their antibiotic resistant genes. The presence of these contaminants should spur more physicians to become knowledgeable about how antibiotic resistant pathogens multiply in wastewater treatment plants and also within their delivery pipe systems. Given this ever increasing threat to the effectiveness of antibiotics, medical professionals must once again show leadership by pushing for improved potable water, waste water treatment and the waste water treatment plant water delivery systems.
Medical professionals have considerable experience giving direction for public health policy how to decrease ARB in clinical settings by eliminating excessive prescriptions of antibiotics, utilizing adequate hand washing technique plus proper disposal of antibiotics. While private practice, clinics and hospitals have focused on this issue, the inadvertent proliferation of ARB by waste water treatment plants and their distribution to the environment vis-a-vis wastewater treatment byproducts remains unaddressed.
The Medical Hydropathology Working Group, which includes a physician and two other researchers, tested recycled water from two wastewater treatment sewer plants in southern California. That testing verified data found in the scientific literature. There is a growing body of published scientific evidence that ARBs are becoming more virulent, prevalent and resistant. Other published scientific data regarding one of the nation’s most modern wastewater treatment facilities documented the presence of ARB and their antibiotic resistant genes in its effluent. Such contaminated effluent puts people living downstream of these facilities at public health risk. Clearly, this is unsatisfactory stewardship of our water resources.
Modern medicine without antibiotics?
Since penicillin was first discovered in 1929, antibiotics have been a critical tool of modern medicine. During WWII, penicillin was widely used to treat bacterial infection. Today, other antibiotics are commonly utilized after surgery as well as for the treatment of various wounds .Prior to the availability of antibiotics, doctors were forced to amputate limbs to prevent the spread of infections. Minor cuts or strep throat were sometimes fatal.
The sewage treatment process inadvertently promotes the lateral transfer of pathogenic antibiotic resistant genes from antibiotic resistant pathogens found within untreated waste water to digestive bacteria purposefully utilized by and necessary in sewage treatment. Such lateral transfer of antibiotic resistant genes continues within our open environment outside of waste water treatment plants between different living types of strains and even various species.
Wastewater is treated to meet minimal federal standards. Although, the three byproducts of the wastewater treatment plants are not intended for direct human consumption, we still might be eating both crops fertilized with biosolids as well as animals that graze on pasture lands (treated with biosolids).We play on public grass irrigated with treated (and still contaminated) recycled water and eat leafy greens, sometimes irrigated with recycled water. In essence, humans are inadvertently, indirectly, and regularly in contact with recycled water and thus exposed to ARB.
As the supply of potable water decreases, public pressure to identify alternative ways to use recycled water increases. Federal, state and local officials and administrators are eager to use recycled water to irrigate both municipal grass and crops consumed raw and for other uses where it is assumed that it will not be consumed– (such as water used to extinguish forest fires and in the process of hydraulic fracturing). Additionally, there is much talk about using even more recycled water as drinking water. It is in the nature of water to move and thus we cannot be assured that these uses will not end in human exposures to ARBs. Wastewater treatment plants are expected to remove harmful bacteria and other micro-organisms. Unfortunately, our current wastewater treatment facilities and technologies are inadequate to this task . Such inadequate treatment of ARB is possibly putting public health at serious risk. (In both lakes and rivers, drinking water is taken from the same areas where presumably treated sewage is discharged.) Therefore, it is essential that we increase our monitoring of ARB in both byproducts (effluent and recycled) of released waste water and also in drinking water. The monitoring should take place both at the end of the wastewater treatment plant and at the end of the water delivery pipes.
Physicians and other health care professions must begin to appreciate and subsequently publicly raise this issue. Health professionals must call for the redesign of sewage treatment plants and their delivery pipe systems and we must plus upgrade monitoring are opportunities for innovation and updating of our infrastructure. Such will also create a great many jobs. Policy changes will be critical to assist in the prevention of illness. Once properly treated, recycled water could be reconverted to potable water, utilized to irrigate crops consumed raw, fight fires, or irrigate parks and playgrounds. It is time that we start monitoring and set public health based standards that will eliminate ARB and their antibiotic resistant genes.
As physicians, we understand the need to treat clinical problems and our broader duty to identify new public health issues so that we can also prevent future illness. The State of California and our elected officials must do the same. They must improve our waste and drinking water treatment facilities and water delivery systems so they can eliminate ARB while simultaneously developing methods to quantify ARB and their resistant antibiotic genes in all of our water resources. It is our job as health care professionals to educate and build political will in order to mobilize public agencies and other reclaimed water advocates to act toward this end.
We are at a critical juncture that could lead to the loss of one of modern medicine’s greatest tools. We must take a preventative approach with new strong policy actions. While we posses much of the technology needed to adequately treat waste water, what is lacking is the political will to fund more research (Is the above contamination dangerous to our public health?) and subsequently redesign our water treatment and delivery systems. It is and has been the role of physician advocates to call for action, please join us in our efforts to educate, engage, and mobilize our colleagues. Also please join our Medical Hydropathology Working Group as we will be hosting a series of conference calls to develop a strategy for eliminating ARB and their antibiotic resistant genes in effluent, recycled water, potable water and biosolids. Please contact John M. Ackerman, M.D. (firstname.lastname@example.org) if you have comments and and/or questions.