On December 11th 1945, at the end of his Nobel lecture, Alexander Fleming sounded a warning.
Fleming’s chance observation of the antibiotic effects of a mould called Penicillium on one of his bacterial cultures had inspired his co-laureates, Howard Florey and Ernst Chain, two researchers based in Oxford, to extract the mould’s active principal and turn it into the miracle cure now known as penicillin. But Fleming could already see the future of antibiotic misuse. “There is the danger”, he said, “that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”
A big part of the trouble is that the gains from the overuse of antibiotics are private, whereas the losses are public. Problems such as these are rarely soluble without outside intervention. Ramanan Laxminarayan of Princeton University, who has been thinking for many years about how to deal with the question of resistance, suggests the answer is a mixture of incentives and scourges. Prize funds, or guaranteed-purchase arrangements for new drugs and the rapid-diagnostics systems that would allow them to be deployed appropriately, would help overcome the financial problem of antibiotics being cures, rather than just treatments. Stricter dispensing guidelines for doctors and pharmacists might help deal with the moral hazard of overtreatment.
A bit of realism would be good, too. Derrick Crook, a consultant microbiologist at Oxford, where Florey and Chain once worked, observes, “It is hard to massively restrict the use of antimicrobials when they are doing good. It is possible that the enormous use in Asia is a good thing for a short time in a given country.” That, combined with ignorance about precisely how much the unnecessary use of antibiotics contributes to increasing resistance, makes restriction highly controversial.
Tim Peto, a colleague of Dr Crook’s at Oxford, though sceptical of the idea that resistance might bring about a catastrophe, also notes that much of modern surgery relies on the risk of infection remaining low. At the moment, it is close to zero. If resistant strains raise it to even 5%, let alone 10%, a lot of orthopaedic surgery, cataract replacements and other discretionary but life-enhancing procedures would simply stop. That would not be the end of the world, but it would be a step backwards. And it would be a shame if it had been caused by a failure to take proper notice of a warning, all those years ago, sounded by one of the men whose legacy would thus be squandered.
View full article in the Economist.