The UK’s chief
medical officer (CMO), Professor Dame Sally Davies, made a splash in the
media this week with
her warning that antibiotic resistance is the new climate change. There is a
‘catastrophic threat’ of ‘untreatable’ diseases, she said, which promise to
return us to a ‘nineteenth century’ state of affairs. The CMO has form: she warned the House of
Commons health select committee about the same problem in similarly stringent
terms back in January – a case not so much of apocalypse now, as apocalypse
again.
As with all such stories, reading the
actual CMO’s report leavens
some of the hysterical excesses of the press, which were stoked up by the CMO’s
excitable media appearances. Setting out the epidemiology of infectious
diseases in the UK, the report highlights that while some drug-resistant
infections, such as the well-known Clostridium
difficile (C diff) and MRSA,
are becoming less widespread, there is an increasing occurence of harder to
treat multi-drug resistant bacterial infections, which, although still only in
the hundreds of cases per year, are on the rise. The report states that only
five antibiotics to fight such infections are currently in phase II or III
trials, so the cupboard seems worryingly bare of new, necessary drugs.
So if we’re running short on drugs, how
can we make more? A sensible article in the British Medical Journal from 2010 clearly set out the
challenges facing the development of new antibiotics. Firstly, there are many
regulatory hurdles that make running clinical trials in this area difficult.
More importantly, there is a major financial disincentive for drug companies to
develop antibiotics. Currently, drugs which are profitable are those for
chronic conditions that are prescribed lifelong: painkillers for arthritis,
diabetes drugs, and the like. A drug that you take once to cure you is
unprofitable; doubly so if it is likely to be husbanded to prevent resistance
developing until the patent runs out. A change in government payments to
incentivise new antibiotics, like that which already applies to so-called
‘orphan’ drugs for rare diseases, would be an easy and rational step towards
producing more drugs that meet our needs.
While there is some discussion as to
whether the low-hanging fruit of easily produced effective drugs have already
been picked, if you’re not even trying to harvest from the tree, you’re not
going to find any fruit. As the BMJ article states, only 1.6 per cent of
all drugs in development by big pharmaceutical companies are antibiotics.
These are fairly boring and technical
changes to the drug development and reimbursement processes that could have a
big impact, and both are within the government’s gift. To be fair, the report
does recognise these problems, but of 150 pages, only about three look at the
barriers to new antibiotics and prospective research strategies. Out of 17
policy recommendations, covering everything from improved diagnostics and
stewardship of existing antibiotics to the inescapable public-health programme
to ‘improve people’s knowledge and behaviour’, a grand total of zero refer to
the production of new drugs.
So why does the CMO prefer to scaremonger
rather than take steps to solve the problem at its root? Partly, the report
reflects the kneejerk Malthusianism that is prevalent today, and not just in
relation to antibiotics. Everything from food to energy is now seen as being
invariably limited, which means it has to be tightly regulated, apparently, in
order to prevent overconsumption. To this fragile mindset, rational scientific
inquiry and government intervention into the market to solve a problem is seen
as a foolhardy task. The only solution, it seems, is strictly to limit the use
of antibiotics. But practitioners in medicine, of all areas, should be
sceptical of such low horizons. The continual innovation that incrementally
pushes the boundaries of what is possible today, and the explosive creativity
of the postwar medicines boom, so vividly illustrated in James Le Fanu’sThe
Rise and Fall of Modern Medicine, give the lie to these socially imposed
limits.
But the absence of any drive to
manufacture new antibiotics is also down to the free-floating anxiety that
afflicts those in authority. Confronted by a practical problem – in this case,
a possible shortage of effective antibiotics – the medical establishment seems
only able to deal in worst-case scenarios. The CMO’s choice of comparison –
climate change – is deliberate and revealing: an open-ended threat, far off in
the future, that requires exceptional measures here and now. This kind of
‘unknown unknown’ is much easier to deal with than the grubby reality of the
fallout from the Mid-Staffordshire Foundation Trust, where the inept running of
hospitals may have led to 1,200 deaths, or the latest ‘re-disorganisation’ of
the health service. For those at the top, fearmongering functions as a cover
for discombobulation, to put a medical name to an existential problem.
As for the rest of us, the best response
to excitable reports of rampant antibiotics-resistant infections would be to
take chill pill.
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