Michelle A. Williams is dean of the Harvard T.H. Chan School of Public Health.
The Review on Antimicrobial Resistance, a project supported by the British government and the Wellcome Trust, predicts that, by 2050, drug resistance will claim 10 million lives a year worldwide. Closer to home, the Centers for Disease Control and Prevention estimates that 2 million people in the United States will suffer drug-resistant infections annually, and 23,000 will die. These numbers are likely dramatic underestimates: A 2018 study from the Washington University School of Medicine put the number of deaths between 153,113 and 162,044 .
So, yes, we should be scared. But we need not feel helpless.
Although the antibiotic-resistance problem is complex — spanning the domains of clinical medicine, basic research, economics and government policy — there is a clear path to reversing the situation. We must summon the determination to choose that path.
We are up against natural selection — Darwinian evolution itself. Antibiotics, especially when used improperly and profligately, create selective pressure on bacteria. The organisms most vulnerable to the drugs die quickly, while the most resilient bugs survive and replicate.
How can humankind prevail against nature’s ingenuity? We’ll do it the same way that public health has historically triumphed over infectious scourges such as smallpox and polio, and has fought other entrenched problems such as cigarette smoking, unsafe workplaces and contaminated food. We must marshal a sustained, coordinated, multifront campaign.
Here is one prescription to solve the antibiotic crisis: First, prevent infections whenever possible. An infection prevented is a case of antibiotic resistance averted. Prevention is the essence of public health. In the fight against drug resistance, this means prescribing antibiotics only when they are necessary, especially in outpatient settings such as doctors’ offices and clinics. It means halting the unnecessary use of antibiotics in farm animals, a practice that nurtures drug-resistant organisms in our food supply. And it means channeling more money to hospital infection-control programs — which, unfortunately, are often low-priority budget items.
Second, invest far more money in research and development. Bringing a new antibiotic to market, from basic research through clinical trials, can take 10 to 15 years and cost upward of $1 billion. Yet the profits on these drugs are negligible compared with those for drugs that treat chronic conditions such as hypertension, diabetes or heartburn. Today, there are only 42 new antibiotics in the drug pipeline compared with more than 1,000 candidate drugs for cancer.
To spur research and development, we urgently need new types of financial incentives. One of the most innovative examples is CARB-X, a global partnership launched in 2016. CARB-X is a “biopharmaceutical accelerator” funded by a mix of private philanthropy and international governments, including the Biomedical Advanced Research and Development Authority at the Department of Health and Human Services. It offers 70 percent funding for the projects it selects; provides technical, business and scientific support; and lends its imprimatur to high-quality, early-stage research that private funders and venture capitalists can consider investing in to bring the drugs to clinical-stage development. Most of the research that CARB-X underwrites is carried out by small start-up companies unburdened by big firms’ fixation on the bottom line.
Once new antibiotics come to market, we must break the conventional link between sales and profits. Unlike other drugs, new classes of antibiotics will need to be preserved as long as possible, through limited use. That means their profitability should be tied not to sales but to their social value.
Earlier this year, Jim O’Neill, a former Goldman Sachs chief economist who chaired Britain’s Review on Antimicrobial Resistance, suggested nationalizing antibiotics production, such as through a taxpayer-supported utility that would focus solely on drug manufacture and distribution. Others have floated the idea of a for-profit company for which the core investors would be governments and charities, with the rest owned by the public. Unlike large pharmaceutical firms, these utilities would not expect blockbuster profits on their products — just a steady 4 percent or 5 percent rate of return.
Finally, we must reframe the way we think about antibiotic drugs. Like our rivers and forests, they are precious resources. Like our highways and bridges, they are public goods that should be available to all. Put simply, we must bring a collective moral vision to this high-stakes battle.
Reversing the tide of antibiotic resistance won’t be easy. The issue is similar to climate change in that it seems distant, abstract and insidious, but is potentially catastrophic for those it affects. Unlike with climate change, however, there are no “antibiotic resistance deniers.” Experts agree that this crisis is solvable with science and with money. The time to act is now.