Antibiotic Resistance on the Rise, Thanks to Capital Misallocation on a Grand Scale
Filed under: Bioethics, Drug Pricing, Drugs & Medical Devices, Economic Analysis of Health, Pharma
As Kevin Outterson & Aaron Kesselheim have been arguing for years, antibiotic resistance is a huge and growing problem. The Guardian’s Frank Swain offers an international perspective:
An unusually hardy strain of Klebsiella pneumoniae was isolated from a 59-year-old Swedish patient who had been treated in a New Delhi hospital. The bacterium was found to be indifferent to even our most powerful antibiotics. To make matters worse, the genes that gave it this superpower were found on a small ring of DNA that is easily traded between different species of bacteria.
New Delhi metallo-beta-lactamase (NDM-1) has since turned up in more than 16 countries across the world, including Britain. A study published in Lancet Infectious Diseases today shows the resistance factor has spread to 14 different species of bacteria. . . In a report published last year, the US Institute of Medicine described antimicrobial resistance as “a global public health and environmental catastrophe”, while the WHO called the rise of NDM-1 a “doomsday scenario of a world without antibiotics”.
Econbloggers on both left and right are worried. But the chairman of the Board for the Canadian Committee on Antibiotic Resistance says that, despite these tocsins, “The problem is that it is somewhat akin to climate change and so slow and insidious that people, and notably our politicians, are lulled asleep.” I am worried by the chair’s climate analogy: it may speed antibiotic activism to the same graveyard of “socialist ideas” that high speed rail recently crashed into. (Yes, that metaphor was as ugly as the political process that provoked it.) Obama advisor Cass Sunstein’s dismissal of the precautionary principle is far closer to administration policy than, say, Lisa Heinzerling’s, Robert Verchick’s, or Greg Mandel’s and James Thuo Gathii’s rehabilitations of the concept. Official Democrats endlessly dither over risk prospects, while Red America is not even that concerned:
One of the most Republican demographic groups — affluent white men — is the demographic with the highest number of confident risk takers. Among academic researchers, this phenomenon is known as “the white male effect.” A 1992 study reported in the journal Risk Analysis found that, in a survey of 1,512 people, men saw less risk than women from each of twenty-five potential health hazards including nuclear waste, pesticides, blood transfusions, radon, and X-rays: “Sizeable differences between risk perceptions of men and women have been documented in dozens of studies. Men tend to judge risks as smaller and less problematic than do women.”
Why invest in future antibiotics if risk is seen as so manageable? As Edsall noted, in other studies of Americans, “fully 69 percent believe[d] they are ‘above average’ in their overall personality and character, and 86 percent [said] their intelligence is above average.” A culture of “self-help” encourages individuals to think they can outwit the superbug, if they are smart and savvy enough.
But there is a deeper problem that American culture is only beginning to grapple with. As FT editor Martin Wolf recently noted in a address at the LSE, the US has been the beneficiary of enormous capital inflows since the beginning of the Bush administration, and has spectacularly wasted them. Charged with efficiently allocating capital, the finance sector has instead opted, by and large, for get-rich-quick schemes. That mentality has affected every sector, including pharma. Even in a society where national priorities are set by an increasingly small group, one would think that drug-resistant bacteria would stir some coordinated response. But when money is primarily thought of as a way to earn more money, even the most pressing needs can be left neglected. Perhaps that’s why Americans are increasingly suspicious of the “free market” and financial institutions.
Recommended Reading: Recent Legal Scholarship on Issues in Global Public Health
Filed under: Global Health Care, Recommended Reading
Redressing the Unconscionable Health Gap: A Global Plan for Justice (published in the Harvard Law & Policy Review). In this article Lawrence Gostin brings a big picture issue — the vast global health gap between rich and poor — into perfect focus. Professor Gostin reminds us of an “uncomfortable truth” — “that closing the health gap is well within the means of the international community” — and he proposes a simple (in concept if not execution) plan to do just that. No international treaty would be required; Professor Gostin’s Global Plan for Justice would take the form of a World Health Assembly resolution. No new organization or governance structure would be required either; rather, the World Health Organization would “assume its place as the global health leader.” States would be asked to contribute a small percentage — Professor Gostin suggests 0.25% — of their Gross National Income each year to a Global Health Fund. The WHO would then allocate the Fund’s resources based on “the health needs of developing countries measured by poverty, morbidity, and premature mortality.” Professor Gostin suggests that the mission of the Fund be threefold: “(1) ensure the fair allocation of essential vaccines and medicines, with particular attention to low- and middle-income countries in a public health emergency; (2) meet basic survival needs [e.g. food, water, sanitation, and vector controls] and create the conditions in which people can be healthy; and (3) help countries that will suffer most to adapt to the health impacts of climate change.” Existing efforts, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, demonstrate the power of voluntary collective action; unlike the proposed Global Health Fund, however, they are too narrowly-targeted and inconsistent to close the global health gap. Professor Gostin’s article is short (it’s based on the text of a speech), straightforward, and provocative in the best sense of the word. I highly recommend it.
I also highly recommend Kevin Outterson’s The Legal Ecology of Resistance: The Role of Antibiotic Resistance in Pharmaceutical Innovation (published in the Cardozo Law Review) in which he uses proprietary sales and volume data for the important hospital antibiotic vancomycin to test a number of widely-propounded theories about the interplay between antibiotic resistance and intellectual property law. The vancomycin case study fails to support the hypothesis that a patent holder is likely to zealously market an antibiotic with an eye to the drug’s dwindling patent term, without regard for the risk that increased uptake could accelerate the evolution of antibiotic-resistant bacteria. It also fails to support the hypothesis that if patent terms for antibiotics were extended, patent holders would better manage the sales and use of their drugs to forestall the development of resistance. By contrast, the story of vancomycin is consistent with the hypothesis that antibiotic resistance stimulates innovation — as bacteria evolve that are resistant to an existing antibiotic a market for a new antibiotic arises. All of this suggests that “tinker[ing] with the patent system” is unnecessary and could even backfire. Professor Outterson concludes that a more direct and potentially more effective approach to preserving the antibacterial effectiveness of our antibiotics would be to fix our broken health care reimbursement system, under which infection control is an unreimbursed cost and “hospitals and doctors have generally gained revenues from additional infections[.]“




Posts from Health Reform Watch have been cited by media sources throughout the country, including The New York Times, Washington Post, L.A. Times, Kaiser Health News, The Health Care Blog, NPR's Planet Money Blog, Duke Univ. Med. Center News, American Health Line Alerts, BusinessWeek.com, Concurring Opinions, Balkinization, The New England Journal of Medicine, Harvard's Nieman Foundation for Journalism, Las Vegas Sun, Maggie Mahar, Ezra Klein, Tom Geoghegan, and the official homepage of the Office of the Democratic Majority Leader of the House of Representatives, Steny Hoyer.