Resistance is futile: the new war on drugs
Posted by Sarah Darley on November 8, 2007
In her Oct. 19 post to the Center for Global Development’s Global Health Policy blog, Ruth Levine likens drug resistance to global warming. Dr. Levine has provided not only a useful framework for thinking about the problem of drug resistance but also the push that I needed to craft Common Tragedies’ first public health post (along with some prodding from Daniel Hall).
Dr. Levine notes the following shared characteristics between drug resistance and global warming:
- Both are a result of profligate overuse of a precious resource (fossil fuels, the ability to kill harmful bugs) without mindfulness about long-term consequences.
- For both, we’ve created a situation in which the commercial interests are largely lined up against better resource management and mitigation measures. The power of markets and the private sector is not yet marshaled toward making the situation better. The energy sector makes money on oil not conservation; the pharmaceutical industry may see few gains from taking steps to ensure the long-term effectiveness of low-margin, first-line drugs.
- For both, the government has a crucial role to play in regulation and in providing incentives for better resource management – and in both cases governments have been slow to take on those tasks. Particularly in low-income countries, public officials may also see that actions to mitigate long-term damage have a near-term cost for economic development (if energy conservation is required) and improvements in health conditions (if it’s necessary to slow drug access until stronger systems to ensure adherence are in place).
- Both can be ameliorated only with a combination of significant behavior changes (by consumers, health care workers, patients) and technological developments (energy-efficient cars, solar power, new diagnostics and drugs).
- For both, understanding the severity and causes of the problem, and the feasible solutions is only possible if we think about the planet as one world, with global goods – and bads – that call for collective action.
Much of the recent Common Tragedies banter has centered on policy responses to climate change and, in particular, the relative merits of carbon taxes versus cap-and-trade programs. Given the similarities outlined by Dr. Levine, one might ask whether potential policy solutions to drug resistance might mirror some of the policy options on the table for global warming.
Building on Dr. Levine’s third point above, policy responses to both problems must reckon with justifying near-term costs in the service of avoiding catastrophic long-term damages. This justification involves segmenting the market to determine which costs are bearable – some fossil fuel use is necessary and some can be displaced; some antibiotic use is “appropriate” and some is not. While this segmentation is common across the two problems, you see the dilemma in suggesting something like an antibiotic tax or auctioning off drug permits – we’re not just talking about halting production at a firm with relatively high marginal costs; we’re talking about forgoing life-saving medical treatment.
However, I think this deeper ethical implication does (or should) translate to the global warming debate – in debating about permit-trading versus taxes we certainly must consider that those who will suffer most from the pass-through of carbon prices (assuming no revenue-recycling) are those whose energy use tends to serve more vital purposes than powering a flat-screen HD television or joy-riding through the suburbs in a Hummer.
In the end, market failures are still the crux of both problems, and these can be corrected with incentive-based policies. Dr. Levine gives a nice shout-out to RFF’s “Extending the Cure” project as an outfit that is promoting such policies to better manage our shared resource of antibiotic effectiveness in the US. For instance, Medicare, as a major payer in the healthcare system, has the leverage to encourage hospitals to pursue best practices regarding infection control and antibiotic use by linking its reimbursement practices to such behavior. On the supply side, we should consider structuring our patent system to encourage drug companies to care about evolving resistance to their products, and we should also pursue more aggressive incentives or perhaps prizes for novel antibiotic development.
RFF Senior Fellow Ramanan Laxminarayan, principal investigator for Extending the Cure, is also tackling drug resistance on an international scale in his research on subsidies for anti-malarial drugs.
Incentive-based policies are effectively untested on the scale of global climate change or global disease burden. Debating the merits and design of such policies is certainly warranted given the degree of uncertainty we’re dealing with, but, in both cases, the moral imperative to act, and to act justly, cannot be ignored.