Written by: Richard Clark
There is no doubt that antibiotic resistance exists and now poses a very serious risk to the future. This article will focus on the potential global economic impact of anti-microbial resistance (AMR), as the economic argument is crucial in convincing people to take action. For those in industry and policy-making, this is an issue that needs to be tackled now and not later.
Before we assess the impact, a brief explanation of how AMR develops in bacteria puts the severity of the issue into context. Antibiotic resistance develops via the process of natural selection – the resistant bacteria outlast the non-resistant bacteria and are left to divide and multiply. However, what makes AMR even more dangerous is that it spreads via a secondary mechanism. The gene responsible for resistance is contained on a strand of DNA, called a plasmid, which can be shared between bacteria.(1) In this way, the gene can be transferred, copied and integrated, and then transferred again. This two pronged evolution of resistance ensures it progresses far faster than standard evolution via mutation and adaption. The diagram below shows the adaptation process.
In determining the impact of AMR, arguments can only be examined in terms of estimates and trends rather than hard, definite numbers. Numerous studies have highlighted the lack of mainstream attention paid to AMR. Consequently, it is difficult to model such a scenario without much underlying research to back it up.
The most publicised area when it comes to AMR is also where our analysis begins – healthcare and public welfare. Antibiotic resistance is already rearing its head in the form of MRSA and XDR tuberculosis(2), rendering almost all treatments useless. If current trends continue, AMR could have wide reaching implications for the treatment of many bacterial diseases, but also means that even routine surgery becomes nearly impossible(3). Patients will spend, on average, longer in hospital and place a greater strain on resourcing to try to treat even the most basic infections(4). AMR will have a profound economic effect in this area if the current path continues. Estimates of effect on global GDP by 2050 put the decrease range around 1.1 – 3.8%(4), or approximately $100 trillion(5) lower than it would have been, and could be comparable with the 2008 crash except without the cyclical upturn if AMR persists. This decrease in GDP arises mainly from the effect on world population. Estimates by RAND(6) have put the global population between 11 and 444 million lower than it would have been without AMR, and these mortality rates will be a significant factor, given it will shrink the pool of available, skilled labour leading to a decrease in economic productivity. Morbidity also has an effect on the economy, in that, for short term illness, people will be sicker for longer and will have to fight off infection without the help of antibiotics. Longer term ailments, such as joint replacements, which enable those require them to return to the workforce, become extremely dangerous and risky to undertake. Caesarian sections, which are estimated to contribute 2% to GDP(5), will carry a serious risk of fatality to the mother. All of these examples will result in work days and therefore productivity being lost. These estimates are strictly on an economic basis, but it is important to stress the humanitarian implications are also extremely severe. By 2050, an additional 28 million, mostly in developing countries, will be pushed into extreme poverty(4). Recent medical advances could be pushed backwards as they become unfeasible. For the very young or elderly, catching a simple bacterial infection could pose a very serious threat.
A second, perhaps less thought about consequence of AMR, is the effect it could have on agriculture and in particular animal farming. Factory farming and salmon produced in captivity are just a couple of morally questionable techniques of trying to maximise yield of produce by minimising the space per animal required. One of the main issues, apart from the ethical implications of animals suffering, is that animals which are forced to live almost on top of each other allow for the spread of disease far more easily than normal. Indeed, many of the same conditions which open humans up to risk also apply to livestock(7). To combat this, and to keep productivity up and costs down, many of these animals are fed antibiotics routinely to combat this risk of disease, and this a major contributing factor to the spread of AMR. It is important to make an economic argument, as described earlier, to convince those not already that the status quo is nowhere near adequate. Although cheaper and better for profit now, should comprehensive AMR come to pass, current factory farming methods will become to a large extent futile. Farming can foreseeably return to pre-antibiotic levels, which would affect GDP and productivity, as well as social issues such as famine far more likely. There are ways in which high productivity can be achieved without the use of antibiotics, such as a study conducted in Denmark in 2003(8) showed. Being more responsible with our farming methods will safe-guard the long term stability of food production.
It was always a losing war with antibiotics – bacteria develop immunity to one class of antibiotics so another is developed and, important to the economic analysis, sold – but now the tide is turning even more in favour of the pathogens. No new antibiotics have come onto the market since 1987(9) with the numbers of new drugs declining overall. There are examples of possible alternatives, for example proteins with antimicrobial properties in Komodo dragon blood(10), but these are generally a long way off at this stage given scientists will have to explore other fields to solve the problem. In the meantime, it is deemed not profitable enough to explore new antibiotics by big pharmaceutical companies, when compared with other types of drugs. Furthermore, any attempt to cut down on the use of antibiotics in order to combat AMR will hit the pharmaceutical companies in the pocket, and so unsurprisingly they do not push for this. This results in negatives at both sides arising from this stance – new antibiotics aren’t being developed and existing ones are still being pushed by pharmaceutical companies(11). Making the case economically to try to stave off AMR becomes very important in this case, since new antibiotics could be introduced, but currently it is more profitable to divert resources to more profitable drugs. Why would you spend a lot of resources creating a drug which is only taken in short courses, starts becoming less effective from the moment you use it and on average only achieves a profit after 23 years(12)?
Clearly then, big pharma must be incentivised into the R&D of new types of antibiotics. Extending patents, awarding prizes, up-front payments and price hikes have all been proposed, but it remains to be seen which economic arguments convinces R&D in big pharma to pursue the production of new antibiotics. It isn’t all doom and gloom though – the first new class of antibiotics in 30 years has just been discovered and is in the process of upscaling production for human testing(9), but the stark time gap illustrates why more resources need to be devoted.
Anyone would be hard pushed to find a person who thought tighter control and more sensible use of antibiotics wasn’t a good thing. However, serious industry-wide change and therefore societal change will not occur unless the economic argument for staving off AMR becomes a compelling one. Currently, short term thinking and individualism win out over long term planning for the future, because it is more productive, profitable and convenient currently to use antibiotics in the way they are at the moment. Credible economic alternatives need to be devised, which could offer an alternative and a possible way to, at least slow down, the inevitable march of bacterial evolution.
(1) Clewell, Don B(Feb 2014) Antibiotic Resistance Plasmids in Bacteria. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0001491.pub3]
(8) World Health Organization, Dept. of Communicable Disease Prevention, Control and Eradication; Danish Veterinary Institute; Danmarks jordbrugsforskning Impacts of antimicrobial growth promoter termination in Denmark: the WHO international review panel’s evaluation of the termination of the use of antimicrobial growth promoters in Denmark: Foulum, Denmark 6–9 November 2002. Geneva: World Health Organization; 2003