Antibiotic Resistance – Missing the Point?

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The growth of resistance to antibiotics is a potential catastrophe for humanity on the scale of a new pandemic. Imagine a world where the simplest surgery, or the least scratch from your cat, carried the risk of death from septicaemia. I write from very personal experience: a few years ago a routine prostate biopsy resulted in hospitalization, probably because the prophylactic antibiotic was ineffective against some exotic bacteria that had colonized my gut during a recent holiday in South America. I know what sepsis feels like – and I don’t think it would have been a good way to die, if the hospital hadn’t identified an effective drug.

In the UK, on the advice of the Chief Medical Officer, the government has identified antibiotic resistance as a major global concern. The Prime Minister has established a review, jointly with the Wellcome Trust, to devise solutions. Its first report has just been published, focussing on what has been identified as the principal concern, namely the lack of innovation and the development of new classes of antibiotic. The report is certainly useful in raising awareness of the problem. As usual, however, the neglect of any social science other than neoclassical economics rather limits the depth of analysis and the likely effectiveness of the remedies. Curiously, the review also seems to have misunderstood the biology, despite the involvement of leading biomedical scientists.

Dame Sally Davies, the UK chief medical officer, and a member of the review, is fond of using the language of a ‘war’ on resistance. This is a very misleading metaphor: wars can usually be won. Resistance is what evolution is about. Humanity cannot win an outright victory. If we are lucky, well-organized and self-disciplined, we can get ahead for a while. This is Evolution 101. Antibiotics allow a slowly-reproducing population (us) to apply intense selection pressure to a rapidly-reproducing population (bacteria). To the extent that we knock out a large proportion of that population, we simply leave an ecological niche vacant. The speed with which bacteria reproduce – hours rather than years – means that there are many more opportunities for random mutations to occur that resist this pressure and empty space into which they can grow rapidly and without competition.

If we understand this, we should recognize that a global strategy for antibiotic resistance is not a matter of a one-off investment in an innovation fund. It is a challenge to bring about changes that will permanently alter human institutions and behavior. There is no point in improving the innovation pipeline if the drugs come out at the end into the same chaos as today.

The report offers some glimmers of recognition, and further reports are promised, which may deal with some aspects of this challenge. However, the analysis of market failure in this report is not encouraging, especially in its marginalization of regulation and its references to the need to educate consumers not to demand antibiotics where they are unnecessary. The really difficult issues are avoided here in favor of a rather Utopian model of a global purchaser, possibly constituted by G20 governments, that would dominate the market by guaranteeing to buy the output of the pharmaceutical industry. With resistance, domination is not sufficient. Wherever the pipeline leaks, into the street markets and open sewers of the developing world, the opportunity for natural selection is created.

Similarly, we have been telling people for a generation that they should treat health services like consumer goods and subject health professionals to market pressures from customer demand. The idea that professionalization might be a response to market failure rather than a cause of market failure has been largely dismissed. How do we now turn round and say that sometimes doctors do know best, that they can be agents of a community and that patients should accept that the refusal of a prescription might be in their best interest?

Clearly, something needs to be done to encourage research and drug development in this area. However, a great deal could be done to buy time for this to occur by other interventions. One is to enhance the integrity of the supply chain. Part of the problem is clearly that many established antibiotics are out of patent and can be manufactured more or less anywhere by anyone with the right equipment and skills. Local generics manufacturers have even more incentives than Big Pharma to sell antibiotics like confectionery. The report dismisses the idea of extensions to patent life, on the basis of calculations about a rather trivial two-year extension. Suppose we thought about 50-year extensions? Would this not give Big Pharma a real incentive to police the pipeline? An institutional economist or a law and economics specialist would bring a rather different perspective on regulation and intellectual property.

We also know that, even in highly marketized health care systems like the US, that it is possible to teach doctors how to resist patient demands for prescriptions. In fact the basic line of research on this by sociologists and psychologists goes back to the 1970s in the UK. Could we not do more to disseminate this? Educating patients in the mass has been tried for more than a generation in the UK – and failed. On the other hand, if we are going to reward doctors on the basis of patient satisfaction surveys, how can we expect them to refuse at the margins? What do we have to do to institutionalize a presumption against antibiotic prescription for viral or self-limiting conditions?

The evidence of political concern for the threat from antibiotic resistance is welcome. The narrow discussion of the problem and the responses is disappointing but, alas, not surprising.

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