Imagine this scene between doctor and patient. The doctor: “I’ve got good news and bad news”. “Gimme the good news, doc”. “I’ve found you a bed in a hospital”. “Great! What’s the bad news?” “It’s in the Hospital for Incurables”. They were up-front if not exactly upbeat about these things in the old days, but could incurable diseases come back? The question is asked every time a new virus like the latest strain of coronavirus appears.
The last time a coronavirus caused world-wide panic was ten years ago when SARS killed around 9000 people in 37 countries. That’s half the number of victims of the 2009 H1N1 outbreak. Around 18,000 victims is a lot, but it’s nothing compared to the previous appearance of H1N1 in 1918, when the virus infected half a billion people (a fifth of the world’s population) and killed 40 to 100 million of them. At that time there was no treatment, but today antibiotics can cure even something as terrifying as the plague.
There are worries though that the microbes are winning again. Microbes resistant to penicillin appeared within a few years of the drug’s introduction, and since then medical science has been fighting an increasingly serious battle against resistance to cheap and effective first-choice, or “first-line” drugs. Moreover, bacterial infections which contribute most to human disease are also the most resistant: diarrhoeal diseases, respiratory tract infections, meningitis, sexually transmitted infections, and hospital-acquired infections.
The human and other consequences are enormous. In South Asia, for example, one newborn baby dies every two minutes due to treatment failure caused by antibiotic resistance. About 3 million women are at risk of impaired fertility following failure in the treatment of gonorrhoea. Treating multidrug-resistant tuberculosis in South Africa costs around $4300, compared with $35 if first-line drugs are effective. It’s not just in developing countries either. In their gloriously entitled report Bad Bugs, No Drugs, the Infectious Diseases Society of America estimated that 70% of the 90,000 deaths from bacterial infections were attributable to antibiotic resistant strains, and that “for many patients, there are simply no drugs that work”.
Resistance is becoming more serious due to a number of social, economic and behavioural causes. Urbanisation facilitates the spread of typhoid, tuberculosis, respiratory infections, and pneumonia. Pollution, environmental degradation, and changing weather patterns affect incidence and distribution, especially of diseases spread by insects. A growing number of elderly people need hospital care and are at risk of exposure to highly resistant pathogens found in hospitals. AIDS has enlarged the population of patients at risk from many previously rare infections. Global mobility increases the speed and facility with which diseases and resistant micro-organisms can spread.
Irrational use of antibiotics is also promoting microbial resistance. This is due to their being prescribed when not needed or in self-medication, or because patients do not complete courses for financial or other reasons. Antibiotics use in agriculture is another factor. In North America and Europe, half of all antimicrobial production by weight is used in farm animals and poultry, notably as regular supplements for prophylaxis or growth promotion, exposing even healthy animals to frequently subtherapeutic concentrations of antimicrobials. This is accompanied by an increased resistance in bacteria (such as salmonella and campylobacter) that can spread from animals, often through food, to cause infections in humans.
But while new diseases such as the latest coronavirus are emerging and others appearing in new locations (dengue fever in Texas and West Nile encephalitis in New York) only two new classes of antibiotics have been brought to the market in the past 30 years. You may remember that the Human Genome Project was supposed to lead to radical innovation in health care, characterised by new, highly-effective, targeted treatments for a vast range of diseases. It hasn’t happened. Two-thirds of the new applications to the US Food and Drug Administration (FDA) are for modifications to existing drugs rather than new drugs.
There are fears that a pessimistic scenario could come about in which biotechnology never lives up to its promise, the flow of major new treatments dries up, and the profits of big pharmaceutical companies decline, creating a vicious circle where there is less money to invest in long-term R&D to find new products. The discovery deficit is then made worse by investor and government reluctance to continue funding basic research and long-term projects that do not produce payoffs.
As Harvey Rubin pointed out in his 2011 study of pandemics for the OECD Future Shocks project, antimicrobial agents make less money for drugs companies than other prescription drugs. A study of ten-day treatment costs of all new drugs approved by the FDA between January 1997 and July 2003 showed that new antimicrobial drugs cost $137 (all anti-microbial agents) or $85 if anti-HIV medications are excluded, compared with $848 for anti-cancer agents.
Health is one of the indicators in the OECD Better Life Index, that shows what matters to individuals (you can make and share your own index here). It would be interesting to see how the average of all the BLI indices compiled so far compares with what governments think is important, based on budget allocations. It would also be interesting to see within health if conditions that affect or could affect people most are the ones receiving the most funding.