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In the fight against antimicrobial resistance, confronting economic challenges is key

Superbugs: An Arms Race Against Bacteria

William Hall, Anthony McDonnell, and Jim O’Neill
Harvard University Press
2018
246 pp.
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Ever since the advent of antibiotics, scientists and clinicians have warned of the potential for widespread antibiotic resistance. Indeed, the first in vitro study of resistance to penicillin was published in 1940, 2 years before the first patient was even treated with the drug. In the ensuing decades, experts and the media continued to warn about an impending crisis of resistance but were largely ignored by the public and policy-makers.

Public opinion changed when resistance became clinically relevant. In the mid-1990s, methicillin-resistant Staphylococcus aureus (MRSA), a pathogen that had not been encountered outside health care settings, became common in patients who had not been hospitalized. New antibiotics were developed, but with the subsequent discovery of organisms that were resistant to carbapenem—a drug of last resort—now there were patients with infections for whom nothing could be done.

The U.S. Centers for Disease Control warned of “nightmare bacteria,” and global leaders started talking about the problem. Yet the problem of resistance lacked an effective global spokesperson.

In stepped Dame Sally Davies, the chief medical officer of England. Having warned about antimicrobial resistance (AMR) in England in a 2011 report, Davies set off to make sure that other countries recognized the problem. In 2014, the U.K. government and the Wellcome Trust commissioned a review on AMR. Jim O’Neill, a former chief economist of Goldman Sachs, was recruited to lead the initiative.

O’Neill’s review followed a long line of reports that sought to explore the intersection of AMR with infection control, vaccines, diagnostics, and new drug development. But it went beyond earlier reports by examining the incentives that prevent free markets from achieving an efficient solution for the development and use of antimicrobials.

The review had its weaknesses: The estimates of economic burden ($100 trillion) and health burden (10 million deaths by 2050), for example, are not realistic and assume zero change in technology or policies over the next three decades. Nevertheless, and perhaps because of the dire nature of these estimates, it brought the issue of AMR to a broader audience and led to a meeting of the United Nations General Assembly in September 2016.

O’Neill’s new book, Superbugs: An Arms Race Against Bacteria, written in collaboration with Anthony McDonnell, who served as head of economic research for the review, and William Hall, who served as senior policy adviser, aims to bring the issue to a lay audience. In their discussion of incentives for infection control, antibiotic use, and new antibiotic development, the authors are careful to sidestep arguments made by the infectious disease community, which were not grounded in an understanding of the economics of the pharmaceutical industry. The book also deemphasizes the report’s problematic assessments of health burden. What remains is an immensely readable description of the challenges that encourage overuse of antibiotics and discourage new drug development.

The authors propose a $4 billion annual investment in tackling AMR and a tax on companies not investing in antibiotics R&D to support market-entry rewards for companies that are. However, there is greater focus on spending on new antimicrobials than on conserving the effectiveness of the drugs we already have or on changing practices that encourage the overuse of antibiotics.

The focus of the book is distinctly on global AMR issues as they relate to high-income countries. For instance, there is little attention devoted to the issue of lack of access to antibiotics, which kills more people than does antibiotic resistance in low- and middle-income countries.

Antibiotic resistance has much in common with climate change, in that actions in any single country have the potential to affect the rest of the world. No matter where the next strain of multidrug-resistant S. aureus arises, it will become a problem in rich and poor countries alike. And, as with climate change, a key problem is the lack of incentives—for individuals, organizations, and countries—to preserve a global common resource.

The metaphor of an “arms race” against bacteria is outdated. One could argue that the idea that bacteria are our enemy is what got us to the problem of antibiotic overuse in the first place. That said, Superbugs is a worthy exposition of the challenges we will have to surmount to incentivize more responsible antibiotic use until we discover new ways of dealing with infections.

About the author

The reviewer is the founder and director of the Center for Disease Dynamics, Economics, and Policy in Washington, DC, and a senior research scholar at the Princeton Environmental Institute, Princeton University, Princeton, NJ 08544, USA.