Scary theme of the week? Rising antibiotic resistance.
Megan McArdle highlighted this challenge in her presentation at the Kauffman bloggers event on Friday; if you have a moment, check out her chart at the 2:00 mark, showing that resistance to new antibiotics has been developing faster and faster.
You’ll hear more about resistance later in the week, as the World Health Organization will make make it the focus of Thursday’s World Health Day. It’s also the subject of a helpful overview in this week’s Economist.
Antibiotic resistance isn’t new. Indeed, as the Economist notes, Alexander Fleming identified this threat in the 1940s. But it appears to be getting worse. Evolutionary pressure combines with market failure to speed the creation of resistant bacteria:
Convenience and laziness top the list of causes of antibiotic resistance. That is because those who misuse these drugs mostly do not pay the cost. Antibiotics work against bacteria, not viruses, yet patients who press their doctors to prescribe them for viral infections such as colds or influenza are seldom harmed by their self-indulgence. Nor are the doctors who write useless prescriptions in order to rid their surgeries of such hypochondriacs. The hypochondriacs can, though, act as breeding grounds for resistant bacteria that may infect others. Even when the drug has been correctly prescribed, those who fail to finish the course are similarly guilty of promoting resistance. In some parts of the world, even prescription is unnecessary. Many antibiotics are bought over the counter, with neither diagnosis nor proper recommendations for use, multiplying still further the number of human reaction vessels from which resistance can emerge.
In economics lingo, there is an externality. If I take an antibiotic, I get the health or psychological benefits. But I also increase the odds of a new resistant strain of bacteria developing, particularly if I don’t take the drug appropriately. But patients and doctors often don’t take that risk into account when deciding whether and how to use an antibiotic.
That’s a tough problem to crack. The standard economist playbook says we ought to disseminate better information and strengthen incentives so that patients and doctors take these risks into account. Better guidelines for prescribing doctors, perhaps, along with better ways of monitoring and rewarding patients for taking the drugs appropriately. One might even consider a Pigouvian tax to discourage antibiotic use, although that raises a host of concerns of its own.
In addition, we could try to expand the supply of new antibiotics.
That raises the usual questions of how best to encourage innovation through patents, prizes, government-subsidized R&D, changes to the drug approval process, etc. But even intelligent policy can’t overcome nature itself. As the graph from the Economist suggests, the potential pool of antibiotics may be drying up.
You seem to resist the impact of regulation.
There are many countries – Mexico, India – where there is massive overuse of unprescribed antibiotics. This is because no prescription is needed.
Our first move is to make all antibiotic use world wide by prescription only. Then work on a code of ethics and regulations for health care providers.
As the former head of antibacterial discovery research at Eli Lilly (formerly one of the largest players in this space), I could make a number of comments about the challenges in this space. Besuiting this blog, however, I will focus on the economics of drug development in this area.
Lilly no longer plays in this space. The reason for this (and for the decline in FDA approved drugs in this area in general) is that the market does not reward development of antibacterial drugs. The short explanation is that if a company developed a novel, highly potent antibacterial agent, the response of the market would be to reserve it for extremely serious cases where resistance has been seen to other drugs. Vancomycin (a drug Lilly created in the ’50’s) has often been used in this role, though resistance is evolving. While this is important from a public health perspective, it doesn’t make for a very good business case (although drugs like Cubicin, also initially developed at Lilly, have done reasonably well).
When I did modeling for the development of drugs against bioterrorism hazards, I estimated that there would need to be a bounty on the order of $5 billion to develop a new drug that would be reserved against a potential threat. Order of magnitude, I’d say that’s still about right, though there may be quite a difference depending on whether a drug targeting a single bacterial pathogen or a broad spectrum drug is desired…
DSM
Antibiotics can be bought over the counter in Ghana, as can malaria medications. In fact, many medicines are used both as antibiotics and antimalarials, including doxycycline (a malaria prophylactic) and one of the two ingredients in Coartem (a malaria treatment). Malaria medications are also at risk for developing resistance; doxycycline is no longer a reliable prophylactic in Northern Ghana.
In Ghana, some of this problem is address through insurance. Service providers are only reimbursed by the National Health Insurance Scheme if the treatments they prescribe are consistent with the doctor’s diagnosis. Maybe U.S. insurance companies should not cover antibiotics unless a doctor diagnoses a bacterial infection (or other condition that a particular antibiotic might have alternative uses for.)
I would be hesitant to suggest developing countries restrict access to antibiotics, however, especially since this could also restrict access to live-saving malaria medications. Prescriptions are not always easy to come by in rural areas in developing countries. I might instead focus on broad education, since malaria, and hence malaria drugs, are very common in Ghana.
Antibiotics prescribed by doctors in the US are not the problem. In many countries, antibiotics are purchased over-the-counter with no prescription and are readily, easily, and cheaply available. In many countries, including the US, antibiotic resistant bugs are break in livestock which are routinely given unnecessary antibiotics as a preventive measure as opposed to as a cure for illness.
The international pharmaceutical industry (IFPMA) is today talking at the 2011 WHO World Health Day in support of the WHO’s call on governments and stakeholders to implement the policies and practices needed to prevent and counter the emergence of highly resistant infections, and also to provide appropriate care to those seriously affected by these microbes. The R&D-based pharmaceutical industry echoes that call and commits to play its part in addressing the challenge of AMR.
IFPMA President and Astra Zeneca CEO David Brennan commented:
“No single party alone can overcome the challenge of AMR: a multi-stakeholder approach is needed, one that includes leaders in government, science, economics, public policy, and
philanthropy to help come up with creative solutions. The R&D-based pharmaceutical industry recognizes the role it has to play in this area of public health, but seeks support from other stakeholders in creating an environment that ensures new antibiotics continue to be developed. Only through the development of new strategies and new collaborations are we going to tackle the problem of anti-microbial resistance.”
Specifically, the IFPMA and its member companies and associations pledge the following:
1. Continue our investment in R&D programs dedicated to the development of new antibacterial agents.
2. Work in partnership towards a responsible global approach with UN Agencies (principally WHO), national governments, healthcare providers, NGOs and other stakeholders in the areas of education, prevention, innovation, access, financing and capacity-building initiatives.
3. Support the WHO’s work to advise on the appropriate use of these vital medicines.
DOCTORS ARE SPREADING MRSA
We already know one of the biggest reasons MRSA is spreading at an alarming rate and killing people — particularly in hospitals. It’s the physicians! More than half of doctors refuse to wash their hands before a physical examination of a patient. It’s true! Hospital administrators are going nuts trying to find a way to enforce physician hand-washing:
http://www.ethicsoup.com/2009/01/dont-kill-me-doctor-wash-your-hands.html
And then there is the ‘Doctors’ Code of Silence,’ where more than one-third of American physicians surveyed admit they do not report incompetent colleagues — doctors who are alcoholics, drug addicts, or mentally ill — yet these doctors are still performing surgeries and treating patients:
http://www.ethicsoup.com/2010/07/doctors-code-of-silence-many-keep-mum-on-colleagues-incompetence.html
The fact that seldom does any physcian comment, even after significant findings from new reserch, on how they contribute to patient-deaths would seem to support the belief that doctos don’t cross the good old boys line, even knowing bad physicians can kill their patients. I guess that means buddies come first not the hippocratic oath to promise to treat all people fairly and to seek to preserve life.
Four antibiotic resistance experts will address the press this afternoon for World Health Day 2011. Webcast at 2pm PST: http://beaker.sanfordburnham.org/?p=4417
In a truly free market antibiotics would develop themselves as the economic advantages of profligating would ensure widespread reproduction and the health and welfare of their progeny.
It is only the leftist policies of big government that are destroying the natural healing abilities of our antibiotics, only through more tax cuts for the richest will we be able to solve this problem.
In fact if we were to impose an antibiotic tax on the poor with the funds going directly to the richest .005% of this nation, this problem would solve itself.
Oh and unions should probably be illegal since somehow I’m sure they are in part responsible for the decline in effectiveness of our current antibiotics.
This situation will only get worse the longer Obama and his ilk are in power. The sooner we can sweep the halls of government clean and layoff everyone in the SEC and other regulatory agencies, the sooner this problem will be resolved.