Do we see crises coming, and if so, are we in the habit of preventing their arrival? Is our free market system of economics capable of preventing their arrival? In answer to the first question, I think some of us do. As the second, no, especially if it means we do not make so much money so fast. Climate change is an example. The scientific community has made it fairly clear that our addition of infrared absorbing molecules into the atmosphere is causing the planet to warm. The politicians, or at least some of them, wave their arms and say we have to burn less carbon, but who says we have to stop using spray cans? A device that led to air creating the spray would be fine, but hydrocarbons, fluorocarbons, etc are not. How about stopping the manufacture of sulphur hexafluoride? Or reducing the level of application of nitrates to the soil?
So, we are at best a quarter hearted about climate change, but what about other impending problems? It is here I think the answer to my third question is no, and in fact the free market is more than just a part of the problem. One such problem that I think needs more thought is the question of antibiotic resistance. How does this come about? Basically because when antibiotics are used, the surviving bacteria are more likely to be resistant, after all, how else did they survive? This is evolution at work; the survival of the adequate, and being adequate to survive in the presence of antibiotics is to develop resistance to the antibiotic. And the problem is, the resistance can be transferred to further bacteria.
So, how does that come about? The most obvious example comes from agriculture, where antibiotics at low levels are used to promote growth. This helps the farmer’s and the drug company’s profits. The object is not to kill off all the bacteria, but rather to reduce their number, hence the low levels. (If you kill off the lot, digestion is impeded.) So, we have a little fermentation pot where resistant strains can develop, and then be transferred to the general environment. Why is this permitted? Because there is more money to be made by the companies, and a bit more by the farmers. Up to 80% of the antibiotic usage in the US has apparently gone into agriculture, and the big pharmaceutical companies are not going to give away that market. The chances of the farming sector turning down the quicker bringing of stock to the market are somewhat slight. Some do not use them, but only because they can then sell meat that can be advertised as “grown antibiotic-free”. So, maybe the consumer is at fault. Are we prepared to pay a bit more to prevent antibiotics being used this way?
Does it matter? I think so. If antibiotics no longer work, or if there is a reasonable risk they will not work, then medicine goes back a hundred years. The more advanced surgery developed during that period may well have to be abandoned. Surgery in the late 19th century was not something many would want to see their family undertake, let alone themselves. Additionally, many cancer treatments seriously suppress the immune system, and antibiotics are needed to deal with adventitious infection.
Now, for the moment we still have a slate of antibiotics, and while resistance is growing, it is rare to get superbugs resistant to just about all of them. Accordingly, our society is responding to this problem in its usual way: we ignore it, and assume we can find a way around it. The way around it is to have a “last resort” antibiotic, or preferably, more than one. The problem is, what used to be the antibiotics reserved for the most serious problems are now being used loosely and widely. But we can discover more, can’t we? Well, probably not. The first problem is, who is going to do the discovering?
The usual answer would be, big pharma. Nevertheless, success there is somewhat unlikely because by and large big pharma is not looking. The problem is, drug discovery has become hideously expensive, and suppose one was discovered and put away as a drug of last resort, usage would be incredibly small compared with the costs of getting it. The reason, of course, is that to prevent getting resistance to this, it too would be used very rarely. The company would never get its money back. Big pharma wants drugs to treat chromic conditions.
There is another problem. One drug that has had a dramatic increase of sales to the agricultural sector is tylosin, and it, by and large has little use in human medicine, but it is in the class known as macrolides, and if resistance is developed to tylosin, it is quite plausible that resistance will be developed to all those in the macrolide class. The use of third and fourth generation cephalosporins in animals has jumped seriously, and these are essential to human medicine. Why are they used? Almost certainly because of direct marketing. These drugs are convenient to use, but they are by no means the most suitable. There have been large increases in the use of tetracyclines and aminoglycosides in the agricultural sector, the latter class includes streptomycin. This report shocks me because of direct experience. When she was about 40, my wife got severe brucellosis, and the only cure then was serious doses of both tetracyclines and streptomycin. At the time it was a close call what would die first: Claire or the bacteria. Fortunately the bacteria did, but brucella live in animals, and I would hate to see that become resistant.
Will the worst-case scenario actually happen? I don’t know, and hopefully it won’t. Nevertheless, from a strategic point of view, don’t we want to optimize our chances of avoiding disaster? And it is here that the problem is most apparent, because the sufferers of the disaster scenario are not the current beneficiaries. We have an economic model that is almost designed to maximize the chances of disaster. It is not time to panic, but equally, it is also not the time to continue being stupid. If we want to insure our medicine does not descend into the state where serious surgery is to be avoided, should we not be cautious and defend what we have? Or do we say, let the corporations make what they can now, and not worry, and hope we never need the antibiotics?
The day after first posting this, the Huffington Post reported: ‘THE END OF THE ROAD FOR ANTIBIOTICS’