Wednesday, September 17, 2014

Antibiotic resistance: Move the money (and control it)!

The BBC Radio4 program Discovery had a two-part series (August 18 and 25th) on the real health danger that we face and the research challenge it presents.  No, not Big Data mapping of diabetes or cancer, or athletic ability or intelligence.  Instead, they were about an impending biomedical disaster, one that essentially trivializes much of which we are throwing away resources on: antibiotic resistance.

Growing antibiotic resistance seems to be imminent or at least inevitable, both in terms of issues like treatment of disease in hospital patients, and in the control of spreadable diseases.  This doesn't seem to be too speculative.  Some strains of infectious bacteria are already resistant to multiple antibiotics, and these are often contracted by hospital patients who were there for some non-infectious reason, and some infectious diseases are not responding to antibiotics at all.

If we no longer have antibiotics, of course, the simplest infection can again become life threatening again, surgery, chemotherapy, kidney dialysis, even an ear infection will become risky again, and infectious diseases will again be the killers in the rich world that they once were.

The antibiotic Novamoxin; Wikimedia Commons

Pharmaceutical firms simply aren't investing in antibiotic development as needed.  Not surprisingly, the reasons are commercial: an antibiotic that becomes widely used may be profitable, but not nearly as much as anticancer agents, or recreational drugs like Viagra, or anti-balding cream.  And, if it's widely used the cost may be lower but resistance is sure to evolve.  If saved for the most dire cases, then sales will be low, cost too high to bear, and not enough profit for the company.

The cost of development and testing and the limited duration of patent exclusiveness present additional issues.  So, nobody is investing heavily in antibiotic development, not even governments that don't have quite the greedy commercial motive for what they do.

The Ebola epidemic is another biomedical disaster that has caught international medical care unprepared.  This is a virus, but there is basically no known antiviral agent; one with some effectiveness seems to be in the works and there are some other stop-gap strategies, but nothing systematic.  But the problem, dangers, and challenges are analogous to the fight against pathogenic bacteria.  Indeed, lately there's been discussion of the possibility--or inevitability?--that Ebola will evolve an ability to be transmitted via the air rather than just physical contact with infected persons.  But of course this is a repeat of the story of SARS, MERS, and other emerging infectious diseases, and surely not the last.

So the question for potential investigators or those worried about the looming disasters becomes: where is the money to solve these problems going to come from?  The answer isn't wholly simple, but it isn't wholly top secret either.

Move the money!
Developed countries are spending countless coinage on the many chronic, often late-onset diseases that have fed the research establishment for the past generation or so.  These are the playgrounds of genomics and other 'omics approaches, and more and more resources are being claimed by advocates of huge, long-term, exhaustive, enumerative 'Big Data' projects--projects that will be costly, hard to stop, and almost certainly will have low cost-benefit or diminishing returns.

We already know this basic truth from experience.  Worse, in our view, many or even most of these disorders have experienced major secular trends in recent decades, showing that they are due to environmental and behavioral patterns and exposures, not inherent genetic or related 'omic ones. They do not demand costly technical research.  Changing behavior or exposures is a real challenge but has been solved in various important instances, including iodized salt, fluoridated water, the campaign against smoking, urban pollution, seat belts/air bags, cycle helmets and much else.  It doesn't require fancy laboratories.

Unfortunately, if we continue to let the monied interests drive the health care system, we may not get antibiotic development.  The profit motive, evil enough in itself, isn't enough apparently, and some of the reasons are even reasonable.  So we have to do it as a society, for societal good rather than profit. If funds are tight and we can't have everything, then we should put the funds we have where the major risks are, and that is not in late-onset, avoidable or deferrable diseases.

Let's not forget that the reason we have those diseases is that we have enjoyed a century or so of hygiene, antibiotics, and vaccines.  The 'old man's friend', pneumonia and things like it, were put at bay (here, at least; the developing world didn't get the kind of attention we pay to ourselves).  But if we dawdle because we're so enamored of high-tech glamour and the sales pitches of the university community (and the for-profit pharmas), and because of our perfectly natural fear of the complex degenerative diseases, we could be making a devil's bargain.

Instead, what we need to do is move the funds from those diseases to the major, globally connected problem of infectious diseases (and similar problems combating evolving pests and infections that affect our food crops and animals as well).  We need a major shift in our investment.  Indeed, quite unlike the current Big Data approach, combatting infectious diseases actually has a potentially quick, identifiable, major payoff.  Some actual bang for the buck. We'll need somehow to circumvent the profit and short-term greed side of things as well.  Of course, shutting down some labs will cost jobs and have other economic repercussions; but the shift will open others, so the argument of job-protection is a vacuous one.

"What?!" some might say, "Move funds from my nice shiny omics Big Data lab to work on problems in poverty-stricken places where only missionaries want to go?" Well, no, not even that.  If plagues return, it won't matter who you are or where you live, or if you have or might get cancer or diabetes or dementia when you get old, or if you've got engineered designer genes for being a scientist or athlete.

The battle to control infectious diseases is one for the ages--all ages of people.  It perhaps is urgent.  It requires resources to win, if 'winning' is even possible.  But we have the resources and we know where they are.

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