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.
Thanks to mass media and social media, awareness of risks (and imagined risks) is growing, while at the same time local difficulties can quickly become global shocks due to the increased physical and virtual mobility of people, concepts and things. But resilience has increased too. For instance, power failures rarely last long in OECD countries because providers have backups and can call on diversified sources. France had to shut or power down 17 nuclear reactors during the 2003 heat wave, but that didn’t deprive any customer of electricity.
But is diversity necessarily a good thing? Cybersecurity for instance is made much more difficult because of the multiplicity of software platforms, infrastructures, telecom networks, norms, and so on that a system depends on. But having only one operating system to attack may not be such a great idea either.
The lonely hacker creating global chaos has yet to materialise, but the fact that what seem like minor problems can now provoke major disruptions reveals an aspect of the risk landscape that will grow in importance: asymmetry. Greece’s GDP is only around $305 billion compared with over $16 trillion for the EU as a whole, but the prospect of a default is causing panic worldwide due to the numerous connections among financial markets that amplify the scale of problems, as we saw with the subprimes crisis. And to stick with finance, the number of traders actually speculating on Greek debt is tiny compared to the power they have.
In addition to asymmetry and amplification, a third “A” is likely to become more important: asynchronicity. This is to be expected as the complexity and number of interactions grow. It could take a number of forms, varying from lags between economic activity and commodity prices to decoupling of countries or regions from swings in the global economy. Asynchronicity complicates the risk landscape because it undermines the case for global solutions to a number of problems.
Why care? And if we do care, what can we do about it, given the scale and intricacy of the problems?
In reply to the first question, the number of people affected by catastrophes is increasing and with it the human and economic costs. Population growth and settlement patterns are putting a growing number of people at risk from natural phenomena such as floods, storms and droughts.
The number of recorded technological disasters such as explosions, fires, and transport accidents has also risen rapidly since the beginning of the 1970s, and economic expansion and competition, combined with greater concentrations of population, will increase the associated risks.
The last major new health catastrophe to appear was HIV/AIDS, but new diseases such as SARS and H1N1 continue to emerge and others are evolving, leading to fears that at some stage a dangerous, new global pandemic is inevitable.
Terrorist attacks remain a constant threat and the world financial system has learned nothing from major crises.
The question as to what we can do is more difficult. The pace seems to be accelerating, but if crises come more quickly, they go more quickly too. The last recession was due to the unravelling of a number of tensions in the system. These tensions were not reduced thanks to any government policy, but built up until they exploded into a systemic shock that plunged the world into a recession and would have destroyed the financial systems if states hadn’t pumped trillions of dollars into the economy. Is pay up and wait for things to improve really the best we can do?
OECD work on risk management in agriculture, arguing that government policies should focus on planning for catastrophic risks like floods and droughts, instead of getting involved in normal farm business risks like price variations.