The new Obama plan to combat antibiotic overuse

by on September 19, 2014 at 2:48 am in Current Affairs, Law, Medicine | Permalink

The Obama administration on Thursday announced measures to tackle the growing threat of antibiotic resistance, outlining a national strategy that includes incentives to spur the development of new drugs, tighter stewardship of existing ones and a national tracking system for antibiotic-resistant illness. The actions are part of the first major federal effort to confront a public health crisis that takes at least 23,000 lives a year.

The full story is here.

The Hill has more detail.  It is an executive order:

The president’s directive creates the Task Force for Combating Antibiotic-Resistant Bacteria, co-chaired by the secretaries of Defense, Agriculture and Health and Human Services.

The group is charged with implementing a plan to track and prevent the spread of antibiotic-resistant bacteria, promote better practices for the use of current drugs and push for a new generation of antibiotic medications.

To that end, the White House on Thursday announced a $20 million prize “to facilitate the development of rapid, point-of-care diagnostic tests for healthcare providers to identify highly resistant bacterial infections.”

The added incentive and the timeframe given to the task force indicate the urgency with which the administration is acting, said Dr. Eric Lander, who co-chairs the President’s Council of Advisors on Science and Technology.

“This is a pretty tight timeline to now come up with a national game plan,” Lander said.

There is also this:

In December, the Food and Drug Administration (FDA) unveiled a plan to phase out the use of antimicrobials for the purpose of fattening chickens, pigs or other animals destined for human consumption. But the plan relies in part on voluntary industry cooperation, and advocates argue the government’s efforts are lagging behind even some industry players.

Here is the new full 78 pp. report to the President on antibiotic resistance (pdf).

This initiative — or its failure — is potentially a more important health issue than Obamacare, yet it will not receive 1/1000th of the attention.  Without reliable antibiotics, a lot of now-routine operations would become a kind of lottery.

Here are previous MR posts on antibiotic resistance.  I would note it is difficult to judge such a plan at the current level of detail.  It is better than nothing, but any initial plan is going to be not nearly enough, relative to an ideal.  By the way, Alex tells me there is also a British prize, discussed here.

1 dan1111 September 19, 2014 at 4:14 am

Kudos to Obama for this.

2 Adrian Ratnapala September 19, 2014 at 10:10 am

I don’t know. If this plan is effective, then yes, kudos. But since I have no idea if it will help, I will reserve my praise. The temptation is to reward Obama simply because he has correctly chosen an important issue where government intervention is probably appropriate.

That is, the temptation is to say “Something must be done! That’s something, so go do it!”.

3 Dan Weber September 19, 2014 at 10:57 am

It’s not likely to cause harm. I think the chance of success is low, but better trying to find a candle than curse the darkness &c &c. And if it doesn’t work, the errors could help the next administration figure out the better course of action.

I agree with Tyler that this is much more important than Obamacare.

4 dan1111 September 19, 2014 at 11:39 am

Obama deserves credit for highlighting this as an issue and making it a high-level priority in his administration. No, that doesn’t equal success, but it is praiseworthy nonetheless.

Also, the prize, the one concrete initiative announced, seems like a good idea.

5 TMC September 19, 2014 at 12:15 pm

“The temptation is to reward Obama simply because he has correctly chosen an important issue where government intervention is probably appropriate.”

Pretty big reversal in approach for Obama. I’m willing to give him credit here.

6 mulp September 19, 2014 at 2:33 pm

You mean giving up on We the People electing useful representatives to Congress to address the national issues?

7 dan1111 September 20, 2014 at 5:22 am

I’m pretty sure that is not what TMC meant.

8 mulp September 19, 2014 at 2:32 pm

Thank god We the People are electing people who refuse to do anything, arguing that we should count on the profit motive and high government payments through Medicare and Medicaid to find a cure for MRSA, malaria, ebola, …

And then argue the way to speed the development of cures is to cut the spending on the cures by eliminating all regulation and all government spending on medical care so that if the most anyone can afford for the magic pills is $100, the profit motive will deliver an abundance of patent medicines for under $100, just like in the good old days.

9 dan1111 September 20, 2014 at 5:23 am

Zero people are actually making either of those two arguments.

10 Alan September 19, 2014 at 4:42 am

Wait, what? You are advocating restrictions on private businesses? But they use anti-microbials to increase their profits! The hidden hand will look after the rest.

11 ThomasH September 19, 2014 at 5:38 am

This is a clear case of a negative externality just like CO2 emission into the atmosphere or not getting vaccinated — private action causes a non-market mediated harm to others that requires intervention. A tax on antibiotic use would seem appropriate.

12 andrew' September 19, 2014 at 6:02 am

Please stop at clear case of externality.

And don’t worry Alan. They will do it wrong.

13 BC September 19, 2014 at 7:18 am

Is this an “externality” or tragedy of the commons, like over-fishing a fishery until the fish population disappears? In the case of the tragedy of the commons, the solution is not intervention and taxes; it’s private ownership. Auctioning off antibiotic usage rights, putting the proceeds into an endowment, and using endowment returns to provide subsidies for the poor might be one solution. (Actually, there’s no reason that the subsidies need to be tied to the auction proceeds — they could just as well be funded from general taxes and auction proceeds could be used for general spending — but I just want to point out that subsidies can be used to address questions of “fairness” or “access”.) Taxing antibiotic use is similar, other than the question of what the appropriate tax/price should be. It’s not clear to me that public choice incentives lead to better pricing than auctions and private ownership. Perhaps, auctioning rights to some antibiotics while taxing others would provide a natural experiment to determine which leads to better conservation.

On a different note, when multiple antibiotics can be used to treat the same malady, is there something analogous to crop rotation, rotating antibiotics to avoid allowing bacteria populations to build up complete resistance? Did crop rotation methods result from private ownership of farmland or government regulation of farmland usage? (These are not rhetorical questions, by the way. I really don’t know.)

14 BC September 19, 2014 at 7:44 am

Actually, on the subsidies for the poor, the present value of all future usage of a given antibiotic, the auction price, exceeds the present value of the future usage of that antibiotic by the poor (because not every antibiotic user is poor). Thus, the auction proceeds should exceed that which is needed to provide subsidies, and the remainder can be used for general spending.

15 dan1111 September 19, 2014 at 7:52 am

The fallacy of your argument is that this is not “not intervention”. The government would have to artificially limit the supply of antibiotics, and they would have to decide what the right amount of antibiotics should be. There is no less intervention in this model than in taxing the antibiotics.

16 BC September 19, 2014 at 9:21 am

We are probably thinking about a different type of usage right. In my conception, the auction winner would buy perpetual monopoly rights for the production of a given antibiotic (which he could sub-license to actual manufacturers). The government would not decide what the right amount of antibiotic would be. The auction winner would determine the quantity of antibiotics each year to maximize the antibiotic’s useful life before bacterial resistance occurs (including the possibility of preventing resistance forever).

We all have different abilities to manage the supply of antibiotics to prevent resistance and, thus, we all would place a different present value on future antibiotic usage. Let V1 be the value placed by the best manager, V2 the second best, etc. V1 > V2. Let Vg be the value when government manages the supply (through taxation or otherwise). If government manages the supply, we will get Vg worth of antibiotics “for free”. In an auction, the best manager will win by bidding V2+epsilon. He will manage the supply to produce V1 worth of antibiotics before resistance makes the antibiotic useless. Vg <= V1 with equality if and only if the government happens to be the best manager of supply. We can use Vg of the V2+epsilon auction proceeds to pay for the first Vg of antibiotics, so we will have already broken even on that, relative to the government-managed case. In addition, we will have V1-Vg worth of additional antibiotics that we will have to pay for using the remaining V2+epsilon-Vg auction proceeds plus an additional V1-V2-epsilon. That additional amount that we have to pay, V1-V2-epsilon, beyond the auction proceeds is precisely (neglecting epsilon) the additional amount of useful antibiotics that manager1 was able to produce beyond what the next best manager could do due to his skill.

17 dan1111 September 19, 2014 at 12:14 pm

@BC, sorry, I missed the point of your plan. However, I think it unlikely that the monopoly provider would be incentivized much based on preventing antibiotic resistance. The incentives for companies to exhibit long-term strategic thinking tend to be poor–they are judged by the market based on immediate results, and executives making decisions are unlikely to be around in 20 years to be accountable for them. Plus, the monopoly doesn’t prevent other competing drugs from entering the market, so they can’t guarantee a perpetual profit stream.

18 BC September 19, 2014 at 7:27 pm

@dan1111, good points. The perpetual monopoly license would be tradeable/sellable. Hopefully, that would be enough to incentivize even a short-term thinker to preserve the license’s market value. Agreed, though, that if the mark-to-market value of the license is hard to determine, a short-term thinker might be able to use accounting tricks to hide any mark-to-market losses due to over-production of antibiotics. On the other hand, if the licensing revenues derived from the monopoly license were securitized and traded, then maybe there would be an observable “market cap” of the monopoly license.

By “competing drugs”, are you thinking of a drugB that is not exactly the same as drugA so that it doesn’t violate the monopoly for drugA but, yet, is close enough that bacteria resistant to drugB will also be resistant to drugA? I don’t know enough about how antibiotics are defined, i.e., how different drugB must be from drugA to be considered different, to know if this will be a problem.

19 dan1111 September 20, 2014 at 5:29 am

@BC, “competing drugs” simply means a similar antibiotic (or other drug) that can treat the same thing. That would erode the value of monopoly rights, regardless of whether resistance comes into play. If a company expected competing drugs to be developed in 5-10 years, for example, their incentive would be to sell a lot of their monopolized drug now, regardless of issues of antibiotic resistance.

20 BC September 20, 2014 at 6:27 am

If a competing drug exists or is likely to be discovered, then isn’t the right thing (from society’s perspective) to be more aggressive in using the current drug, accepting higher risk of resistance? There is some diversification gain from having multiple drugs when bacterial resistance to the different drugs is not perfectly correlated.

21 Andrew' September 19, 2014 at 8:19 am

Money to the poor? The poor who are buying cheap meat?

Or money to the public good of research?

22 Boonton September 19, 2014 at 8:45 am

the solution is not intervention and taxes; it’s private ownership. Auctioning off antibiotic usage rights,

This is a very odd concept of ‘private ownership’. What exactly is a ‘antibiotic usage right’? Antibiotics are pills, many of us have some sitting in our homes right now and when it comes to animals it’s broadly legal to buy antibiotics directly without a script from a vet.

So please make your argument for a system of regulation to stop the overuse of antibiotics but don’t pretend that it isn’t a massive gov’t intervention. Just because you call the ‘license raj’ an issuer of private property rather than a regulator of private behavior doesn’t magically change the reality of what you are proposing.

23 Aristotle M. September 21, 2014 at 11:37 pm

Even in an privately undistorted environment, there would be a problem of the negative social externality. But it is much worse when you realize that the way the system works currently encourages prescribing too much even with respect to what is truly privately optimal. The way insurance, reimbursement, malpractice, etc. works, the incentive is to overprescribe/overuse. Radical changes to these things so that private actors internalize the costs should be taken. Unfortunately, that is not going to happen, and whatever will happen is probably going to be a kludge to a system that should rationally constructed from scratch. Instead of running behind the problem and trying to counter the effects of previous distortions with other distortions that partially address the issue but then create problems of their own, we need to think about what we want the healthcare system to accomplish, what the particular market failures are, and what the best way to deal with them.

24 The Other Jim September 19, 2014 at 8:46 am

>This is a clear case of a negative externality just like CO2 emission

Meaning, completely harmless?

I wouldn’t go that far. But it is a case of taking an unknown risk for a known gain.

I therefore expect the Obama administration to crack down hard on red states and corporations that don’t give him any money.

25 BC September 19, 2014 at 7:48 pm

On CO2, maybe a solution is auctioning an exclusive license to emit CO2 (which can be sub-licensed to actual CO2 emitters) for some number of years, but the license expires prematurely if global temperature exceeds a given threshold. This is different from cap-and-trade because the government does not set the cap; the license holder does.

If a skeptic wins the auction, then he will presumably license lots of CO2 emissions. If his AGW skepticism is right, then he will earn a lot of licensing revenue without diminishing the value of his license. If he is wrong, then the temperature threshold will quickly reach the threshold and his license will expire early. The exclusive license could then be re-auctioned to someone else (with a higher temperature threshold obviously).

If a non-skeptic wins the auction, then he will have an incentive to balance allowing more CO2 emissions (to earn more licensing revenue) with preventing temperature from rising too quickly (to prevent his license from expiring).

Most likely, a skeptic will win the first auction since a skeptic should believe that he will be able to license more CO2 emissions than a non-skeptic before hitting the temperature threshold. If the skeptic is right, we will all win. If he is wrong, we will quickly discover that, skeptics will tire of losing money (by over-bidding in the auctions), and non-skeptics will eventually end up with the exclusive license.

26 dan1111 September 19, 2014 at 6:02 am

Wait, what? Are you assuming Tyler opposes all regulation, just because he leans conservative?

27 andrew' September 19, 2014 at 6:26 am

He is assuming (mainstream) medicine and (factory) agricultural aren’t already what the government did.

28 Jan September 19, 2014 at 6:38 am

I am genuinely interested in how you think we could roll back back factory farming by getting the government’s nose out of food animal production (without creating other public health risks). And if you’re referring to grain subsidies, by all means, end those now.

29 Andrew' September 19, 2014 at 8:14 am

If you were genuinely interested maybe you could tell me. It’s not really my job to investigate every counterintuitive complex system.

But, for starters, since you brought up grains, do you think grain versus grass-fed beef have any interaction? Do you think grains might have something to do with gut flora? Do you think antibiotics have anything to do with gut flora?

30 Andrew' September 19, 2014 at 8:22 am

Antibiotics are often free. So, there is the part where they never added a Pigouvian tax in the first place that I classify as government dysregulation.

Then you can throw “well you aren’t an anarchist then!” as a cynical, opportunistic wedge strategy, like Alan is attempting. But you’d be wrong on several counts.

31 Jan September 19, 2014 at 8:26 am

Ha. I’m still interested in your story about government and its creation of factory farming.

I guess we agree on the cheap grains for animals program.

32 Andrew' September 19, 2014 at 8:37 am

First off, stop reflexively reacting to my comments. As always, do that for you, not for me.

http://en.wikipedia.org/wiki/Agricultural_subsidy#mediaviewer/File:United_States_farm_subsidies_%28source_Congressional_Budget_Office%29.svg

Second, the question for you, in my opinion, is how marginal is the feed subsidy. Does just a little subsidy completely crowd out the grass fed beef and how much does that mess up the free market response that demands organic antibiotic and hormone free beef.

33 Andrew' September 19, 2014 at 8:56 am

Michael Pollan:
“You start giving them antibiotics, because as soon as you give them corn, you’ve disturbed their digestion, and they’re apt to get sick, so you then have to give them drugs. That’s how you get in this whole cycle of drugs and meat. By feeding them what they’re not equipped to eat well, we then go down this path of technological fixes, and the first is the antibiotics. Once they start eating the [corn], they’re more vulnerable. They’re stressed, so they’re more vulnerable to all the different diseases cows get.”

We subsidize corn. This crowds out grass pasturing. Then corn farmers also form lobbies for added leverage like pushing corn ethanol. It raises the price of grass-fed beef. At a certain point, corn fed probably completely crowds out the grass-fed supply chain (the marginality question). Then people build up expertise in grain feeding increasing the moat to crowding-in a grass fed market once everyone realizes the problem. By the time the government is ready to move (I’ve been seeking out grass fed beef like a drug addict looking to score for at least 7 years) it is too late to do anything than ham-fisted destructive regulation. It is too late to let market marginality work.

34 Jan September 19, 2014 at 9:12 am

You’re either preaching to the choir or yourself.

35 Andrew' September 19, 2014 at 9:49 am

Wrong.

36 louis September 19, 2014 at 10:34 am

Andrew’ — not that I disagree with the gist of your comment, but how does ethanol promotion (which raises the price of corn) lead farmers to use more corn as cattle feed?
Ethanol mandates are their own terrible policy, but they don’t encourage more animal or human consumption of corn.

37 Komori September 20, 2014 at 12:17 pm

louis – I don’t know if this is actually the case, but it is possible. If different parts of the plant are used for the ethanol production and the feed, then subsidizing both uses increases the incentive to plant corn more than either would separately.

38 Dan Weber September 19, 2014 at 11:49 am

In fact, Tyler’s stated priors on regulation at the Federal level is that there is too much, except for the environment and finance, where there is too little. It’s not hard to put this under the “environment” umbrella.

39 honkie please September 19, 2014 at 5:16 pm

If “environment and finance” are as broad a cudgel as the Commerce Clause, we’re in for it.

40 Jan September 19, 2014 at 5:50 am

This is a big deal, but there are two things to watch.
1) The lack of progress on prophylactic use of abx in industrial farming is shameful. FDA hasn’t even been able to require this industry to do anything, like report on or limit certain uses of the drugs—those guidelines are voluntary. But I don’t only blame the administration–the food animal producers are very powerful players and they would be running around with their hair on fire if a stronger regulatory approach was taken. It could affect profits so is of course out of the question.
2) This is really an international issue. Resistant microbes don’t have to go through customs, so we should work with other countries on the problem. I believe France is one of the few rich countries that uses more antibiotics on a per capita basis than us.

41 Rahul September 19, 2014 at 7:28 am

Well if the cannot resist a powerful lobby to do what is right it is still their fault. So yes, I still blame the administration.

42 Jan September 19, 2014 at 8:16 am

No, it is also our fault for not demanding more action. The strongest and loudest voices will on this one. I am really glad Tyler is highlighting this issue.

43 Andrew' September 19, 2014 at 8:23 am

It isn’t my fault.

44 Andrew' September 19, 2014 at 9:58 am

Jan,

Just answer this. Who wants to use antibiotics in the beef?

45 TheDarkestPassenger September 19, 2014 at 10:33 am

From some studies I’ve read, factory farms give cows, pigs, and chickens antibiotics because they put on marginally greater amounts of weight. And the antibiotics cost virtually nothing to give to them. So factory farms get more money when it comes time to sell those animals. But our antibiotics gradually work less well because the bacteria get exposed (and some live) through the antibiotic onslaught leaving behind tougher, nastier bacteria.

Then one day you scrape your knee, get MRSA, and they take off your entire leg.

46 Jan September 19, 2014 at 12:28 pm

You should think long and hard about that and purpose a specific solution. “Bad government”, your default answer to everything, is incorrect.

47 Andrew' September 19, 2014 at 8:18 am

Do powerful lobbies just spring up out of the ground? I guess in the case of agriculture they kinda do. Is it really lobbyists versus the government? Or is it lobbyists and the government versus us?

48 albatross September 19, 2014 at 11:02 am

Yes.

49 Jan September 19, 2014 at 12:33 pm

It’s every man for himself and you know it.

50 PL September 20, 2014 at 7:58 pm

Since the existing participants in the market are acting in ways judged to be unreasonable in regards to antibiotic use for increasing production, perhaps it is good to reduce or eliminate agricultural subsidies and protections that contribute to the outcome?

51 prior_approval September 19, 2014 at 5:58 am

‘is potentially a more important health issue than Obamacare, yet it will not receive 1/1000th of the attention. Without reliable antibiotics, a lot of now-routine operations would become a kind of lottery.’

Well, at this web site, what is the proportion of attention – 1/20? Do pat yourself on the back.

As for the lottery – actually, the lottery is whether or not the hospital you are in is run in a way that places maintaining an essentially sterile environment a higher environment than relying on inexpensive and effective antibiotics to cover up slack practices. See how Ellis Island worked for an extremely effective and hard headed approach to this issue in the pre-antibiotic age. Further note how viruses are unaffected by antibiotics – something like ebola requires effective measures to prevent transfer.

52 andrew' September 19, 2014 at 7:00 am

It is almost impossible to maintain steril conditions. The lottery is based on how doctors and hospitals act in generql and how they treat things like the chronically Ill isolation in addition to drug control. It is an actual public good. That is the first reason not to believe that to be the reason for the late urgency.

53 dan1111 September 19, 2014 at 7:28 am

“[R]elying on antibiotics…to cover up slack practices” is one thing, and having them in case they are needed is quite another. It would be a really big deal if hospitals did not have reliable antibiotics available as a line of defense.

54 prior_approval September 19, 2014 at 10:33 am

‘is one thing, and having them in case they are needed is quite another’

Quite right – which is something the EU recognized several years ago – ‘In a vote that’s non-binding but high profile and influential, the European Parliament has resolved to end “prophylactic use” of antibiotics in farming, and to prevent any “last resort” antibiotics from being used in animals, in order to keep resistance from developing so that the drugs will still be effective in human medicine.

This is a significant development. The European Union has already banned “growth promotion,” the use of micro-doses of antibiotics that cause meat animals to fatten more quickly. What the Parliament is doing here is asking the European Commission, the EU’s law-making body, to add “disease prevention” use to the ban. That’s the delivery of treatment-strength doses of antibiotics to all animals on a farm in order to prevent their becoming ill as a result of the confinement conditions in which they are held. It accounts for a substantial portion of the antibiotics used in agriculture, and is a major driver of the emergence of antibiotic-resistant organisms.’ http://www.wired.com/2011/11/eu-farm-antibiotic-use/

Sad to say, the U.S. still has a lot of catching up to do, as it is only now, assuming that the pharma industry goes along, banning only the most egregious practices – ‘The antibiotics plan relies partially on cooperation from the pharmaceutical industry. Guidance issued Wednesday asks companies to voluntarily remove growth-promotion claims from drug labels, signifying that they could no longer be used for those purposes.

With the guidance, companies have 90 days to decide whether they would adhere to the new policies, though Taylor said some leading veterinary drugmakers have already said they would comply.

The guidance sets out a three-year transition period to allow the agriculture industry time to move away from the widespread practice.

Once the growth-promotion claims are removed from drug labels, it would be illegal for food producers to use the medically important drugs for those purposes, Taylor said.

However, they could still be used to treat, control or prevent disease in animals, an allowance that drew immediate criticism from public health experts.

“Problems can arise whenever antibiotics are fed to animals at low doses for long periods of time,” said Keeve Nachman, a scientist with the Johns Hopkins Center for a Livable Future. “Whether you call it growth promotion or disease prevention, this makes antibiotics less effective for treating sick people.”’ – third link in Prof. Cowens posting.

In other words, nothing will change appreciably in the U.S., except that the same antibiotics will be fed to animals to prevent disease, as noted on the label, as compared to increasing growth, no longer part of a product’s label claims.

Yep, American public health practices at their most effective – for ensuring that pharma companies don’t lose a dollar in sales.

55 dan1111 September 19, 2014 at 11:43 am

Wow, we are way behind Europe. They passed a non-binding resolution nearly three years before we did!

56 mulp September 19, 2014 at 4:09 pm

Whoa!

What we have in the US is Obama power grabbing and executive overreach in violation of the Constitution and the will of the people.

57 dan1111 September 20, 2014 at 5:31 am

@mulp, agreed in general, but does Obama not have constitutional authority to create a task force that will think about a plan?

58 Rahul September 19, 2014 at 6:35 am

The “crisis” with antibiotic overuse & resistant bacteria is something I remember reading for at least 15 years now. Are things really getting worse? Have they stopped coming up with newer generations of drugs?

59 randomworker September 19, 2014 at 7:46 am

yes, I believe they are on their last one or two now.

60 VTProf September 19, 2014 at 8:10 am
61 Axa September 19, 2014 at 10:06 am

McArdle forgot one important factors of tuberculosis resurgence: HIV.

Is the relationship between HIV and TB a really hot political potato? http://www.who.int/hiv/topics/tb/en/

62 prior_approval September 19, 2014 at 11:17 am

Not really – though the breakdown of the USSR probably played a much larger role in creating MDR TB – ‘In Russia and the former Soviet Union, TB has been an acute problem.1 Today, the official estimate of the incidence of TB is about 82 to 83 per 100,000 population. According to Perelman, not all cases are diagnosed, however, and not all patients are registered as incident cases; thus this estimate is an underestimation of the true burden of disease.2 The estimate of 82 to 83 cases per 100,000 population also is an average that includes an incredibly diverse population and thus is not very revealing. Russia is a vast country, and the incidence of TB differs as much as tenfold among geographic regions. It is higher in the eastern portion of the country, with the highest rates in the Russian Far East adjacent to Mongolia, China, and Japan. Areas in that part of the country have an incidence ten times that of Moscow.

Before the breakdown of the Soviet Union, the prevention and treatment of TB were under stringent federal control. After the breakdown, many events occurred to exacerbate the problem of TB. Dislocations in the economy made the population poorer, and poverty is a risk factor for TB. Unemployment and crime rates worsened considerably, which encouraged the spread of TB in communities and the prison population. High levels of migration into the country also contributed to the spread of TB, as did military conflicts and the overall degradation of the health care system, which loosened previously stringent controls on the level of disease in the population.’ http://www.ncbi.nlm.nih.gov/books/NBK62453/

63 Rahul September 19, 2014 at 12:42 pm

Though the one crucial point on which the debate hinges, McArdle states as if it is a self evident axiom:

Antibiotics are an exhaustible resource. We should be treating them like an oil field, or an endangered species.

Maybe, but it isn’t obvious to me why.

Some of the other stuff from McArdle’s article is a refreshingly moderating counterpoint to the quite sensationalist & crisis-like tone of Tyler’s current post:

e.g.

“We are not quite on the brink of some dystopian Victorian future…. even extremely drug-resistant TB “can be treated with a couple of drugs…..more-powerful drugs tend to cost more than the old drugs. In developed countries, it’s manifested in slightly higher average prices of antibiotics……”

64 mulp September 19, 2014 at 4:15 pm

“Slightly higher”?? $50,000 to $100,000 for a course of treatment?

For all but the 1%, the only way those drug prices can be afforded is with government payment or very good insurance, and the 1% have the best in insurance which means they never pay out of pocket for the drugs only they can afford out of pocket.

65 Rahul September 19, 2014 at 4:19 pm

Average prices.

66 Jan September 19, 2014 at 5:54 pm

With the rate of increase in resistance and the fact that only one or two (may be just one now) companies in the world is actually still developing abx, yes it is a crisis. These drugs are only getting less effective. New ones are not on the horizon. Look at the abx pipeline compared to any other drug class and it is extremely serious, already killing a lot of people.

67 Rahul September 19, 2014 at 11:45 pm

If it does turn really bad maybe FDA will bend some corners during clinical trials in allowing in some new molecules?

I don’t see a fundamental technical reason for the antibiotics pipeline drying up. Just that there’s such a small market for a last line antibiotic that it’s hard to make money off it. Perhaps it’s a good activity to transfer to CDC or DoD.

68 Jan September 20, 2014 at 8:50 am

Yeah, they have created a faster pathway to market for promising antibiotics with more regulatory flexibility already and I’d guess they will do more. As far as I can tell the real problem is lack of incentives for companies and figuring out the tough scientific questions. The scientific questions are theoretically surmountable–esp how to hit gramm negative bacteria–but because we aren’t really close to answering those questions yet, we don’t know how long and how much research it will take. I do think DoD researchers and maybe CDC will be working on it. CDC doesn’t usually take on too much basic science questions, but NIH certainly could be doing more.

69 Rahul September 20, 2014 at 9:30 am

What fraction of the resistant bacterial cases are gram negative?

Also, out of curiosity, take something like penicillin which has been around longest, is there a quantitative measure of how effective it was when it was novel versus now?

70 PL September 20, 2014 at 8:00 pm

@Rahul:
When penicillin came out, the dose required for effect was say 50,000IU. Now for “susceptible organisms” the dosage has increased to say 2.5 million IU. (numbers not accurate, just for illustration)

71 Edward Burke September 19, 2014 at 8:40 am

By executive order Obama has tasked his Secretaries of Agriculture, Health and Human Services, and . . . Defense?

Not to dump overmuch on the current Defense Secretary, but what is it with Obama’s newfound appetite for dispatching the military to address public health matters (Obama has also ordered 3000 troops to “combat” the spread of Ebola in the past week or so)? Have the VA fiascos of the past year not inspired enough confidence? (BTW: I’ve heard no reports whether the brave 3000 will be eligible for combat pay for their assignment.)

Could Obama be suffering from some kind of administrative or executive tapeworm?

72 Boonton September 19, 2014 at 8:51 am

It’s actually not that uncommon for the US military to be deployed to help address humanitarian crises and it’s quite sensible too. Setting up supply lines, quickly establishing a field hospital and treating patients, rescue missions…these are all things an army has to do well if there is a major war so keeping them in good shape while also helping people is a nice double win.

73 Edward Burke September 19, 2014 at 9:17 am

No doubt, we’ve seen the US military respond to earthquake recovery, hurricane relief, et cetera.

But what exactly will Chuck Hagel bring to a domestic war on antibiotic-resistant bacteria? I cannot think it will consist of setting up redundant supply lines, field hospitals, and rescue missions, not even burial details.

Don’t get me wrong: I appreciate that our Commander-in-Chief is unilaterally declaring war on pathogens from viruses to bacteria, however . . . .

Well, but then, Hagel could well receive the order to commandeer the Federal Centers for Dissemination of Coronaviruses, a domestic public health benefit could come into play there, I suppose, but then the commandant of any military base could probably accomplish that task.

74 aaron September 19, 2014 at 9:57 am

The US military has a rather large medical research community, and a rather large interest in antibiotic resistant infections.

75 Edward Burke September 19, 2014 at 10:20 am

Granted, this does present a fine opportunity to put VA administrators and service providers to good use . . . .

76 mulp September 19, 2014 at 4:24 pm

The military has a larger medical establishment than the VA and does more research into fighting disease – disease is historically the primary killer of those who serve in the military, and the primary reason for being unable to fight. You aren’t going to be very effective if suffering from diarrhea, even as a truck driver delivering supplies to the rear.

77 Boonton September 19, 2014 at 11:38 am

But what exactly will Chuck Hagel bring…

Leadership. It signals to the military that this project is high priority.

78 TMC September 19, 2014 at 12:25 pm

So a grownup is involved now?

79 NPW September 19, 2014 at 9:22 am

The US military doing humanitarian work is fairly standard practice for us and there is quite a bit of foriegn aid delivered through the DoD buget.

80 Willitts September 19, 2014 at 11:48 am

You are correcr, but recognize that this is hands on training for a biological attack during wartime.

Disease has historically killed more soldiers than bullets – less so today but still a concern. And that’s without biological warfare.

81 honkie please September 19, 2014 at 11:33 am

When we find the hospital full of MRSA, who else is going to drone strike it?

82 Willitts September 19, 2014 at 11:51 am

The VA is not part of the DOD, and there is little overlap between military health centers and VA centers.

83 Jan September 19, 2014 at 5:51 pm

This is mostly to do with the fact that DOD and VA (both mentioned) operate a lot of health care facilities which, like all health care facilities, face antibiotic resistance and will need to play a part in addressing it through better stewardship and potentially research.

84 jk September 20, 2014 at 5:28 am

There is a possible risk that Ebola could be airborne. It will be interesting to see the fallout if a US troop is infected by Ebola or passes it to their family or communities when they return.

I wonder if there is a plan to quarantine these people when they return since the incubation period of Ebola may not be fully understood. Can’t wait for Fox/CNN showing the US troops in an isolation chamber for 2 months after returning from W. Africa talking to their families through mics. I wonder if there is plan to destroy or decontaminate all the equipment (planes, clothing, supplies) after being there.

Also there is the hypothetical possibility that Germany based US troops could be denied re-entry to Germany from the German government.

There is also a force protection issue given that there are Muslim terrorist in the region. Forget suicide bombers: What if they wanted to infect the US troops food supply or medical equipment donations to the Liberia et al. governments by having infected individuals simply spit or bleed into these items.

Good intentions, that’s what matters!

85 Nathan W September 19, 2014 at 8:44 am

Probably some of the lowest hang fruit in public health lie here.

If you can persuade people to always finish their course once they start it. It won’t cost a penny more since you already bought it, or anyways if you’re already saving for next time you’re probably taking it too much but pleeease finish your course this time.

Leaving the 1% hardiest/luckiest bacteria by not finishing a course of antibiotics is a surefire way to contribute to the problem.

If someone can find particular markers of antibiotic resistant strains which will be easily picked up by a test, it almost certainly part luck, but mostly facilitated by skills/knowledge/experience. It would be a different test for each type of bacteria. And moreover, it may not be that useful to correctly identify the bacteria, but not the resistant type. I don’t think you’re going to get under as much time as it takes to run an assay, which can be quick, but isn’t anything like, say, a pH strip test.

86 dan1111 September 19, 2014 at 8:54 am

Thinking that patient compliance is low hanging fruit is one of the biggest healthcare fallacies out there.

87 steve September 19, 2014 at 10:18 am

Very high hanging fruit. We aren’t that good at changing people’s behaviors.

Steve

88 mulp September 19, 2014 at 4:31 pm

You mean the behavior of being working poor with kids to feed and thus not paying $50 for drugs for the next month of 9 months instead of using the $50 to feed the kids?

That some drugs require refrigeration and a lot of the people with the drug resistant bugs not having refrigerators is presumably a behavior problem?

Perhaps not living where electricity is provided is a behavior problem?

89 Steve September 19, 2014 at 10:19 am

Reminds me of how proper tire inflation is the low hanging fruit of automobile fuel efficiency. All we need to do is make sure people are keeping their tires at the right PSI. Simple as that!

90 Boonton September 19, 2014 at 11:41 am

Small air compressor built into the wheels themselves to automatically adjust the tires without human involvement. If you’re just tweaking tire pressure rather than trying to blow a tire up that is flat it could be made smaller and lighter to ‘trickle’ the air in.

91 Rahul September 19, 2014 at 1:37 pm

Or less leaky rubber?

92 Urso September 19, 2014 at 10:51 am

All we have to do is convince everyone on earth to act perfectly rationally at all times, and all our problems are solved!

93 Nathan W September 20, 2014 at 2:41 pm

Doctors rarely explain why. If they explained why more people would finish the course.

Twice, I have bought over the counter overseas (not allowed in Canada). In Morocco, after getting a lung infection, I went to the pharmacist and insisted that I needed an anti-biotic. I asked him if there was any difference in the four and seven day options. I even specifically asked if it mattered if I finish them (just of out curiosity) and he shrugged his shoulders. We both spoke very good French so language was not the issue. A second time, in China, the pharmacist repeatedly tried to insist that I had to go to the doctor first, but I insisted that it would waste my time and money to go to the doctor and I the ear infection was getting worse without an antibiotic. It was my advance promise that I understood why the doctor was there as the barrier, and that I would 110% for sure complete the course, that finally led her to allow me to get my hands on the stuff without a prescription.

In most of the world (not Canada) you can buy antibiotics over the counter. This is probably the biggest problem. After that, the fact that doctors do not explain WHY it is important to finish the course.

94 Mitch Berkson September 19, 2014 at 10:28 am

> If you can persuade people to always finish their course

Antibiotics in bacon form?

95 dan1111 September 19, 2014 at 11:45 am

Bacocillin will not reduce antibiotic use!

96 Rahul September 19, 2014 at 1:47 pm

Regulate bacon!

97 Axa September 19, 2014 at 10:15 am

(2) Develop alternatives to antibiotics in agriculture……….so it’s not about prohibiting the use of antibiotics to raise chicken faster. Fundamental research on alternatives, make the antibiotics a bad alternative. At least the objective is well aimed, hope the researchers do find an alternative to antibiotics.

98 Rahul September 19, 2014 at 1:48 pm

What if they kept a separate series of antibiotics for vet use? At least for factory farm use? They could release new drugs faster there. Not as much testing needed.

99 pwb September 19, 2014 at 11:01 am

One restaurant chain has decided its worth their while to not use antibiotics in their food production.

http://www.cnn.com/2014/02/11/health/chick-fil-a-chicken-antibiotics/

100 Urso September 19, 2014 at 11:32 am

Chick-fil-a is some kind of a miracle company.

101 Urso September 19, 2014 at 11:44 am

From the same link, American mom wants European M&Ms:
“a Change.org petition begun by Renee Shutters … is calling on Mars to stop using artificial dyes in its American M&Ms … Shutters says her son Trenton showed noticeable improvements in mood and attention span after she removed artificial coloring from his diet a few years ago…. ‘I just could not believe that something so small could make that big of a difference,’ Shutters says.”

I think she should stick with her first instinct.

102 Jan September 19, 2014 at 5:44 pm

Wasn’t Chipotle the first big chain to do this?

103 dkfj September 19, 2014 at 11:04 am

All the infrastructure that goes towards making sure narcotics aren’t abused should instead be redirected towards making sure antibiotics aren’t misused. I don’t care if someone ODs on oxycotin but I really care if he is breeding multi-drug-resistant TB in his body.

104 Nathan W September 20, 2014 at 2:45 pm

I’d back that policy in a second. The prospects for net social gain are much higher.

Keep in mind that most people who OD on oxycontin are on the stuff because they suffer from a lot of pain. You should be more compassionate.

105 The Anti-Gnostic September 19, 2014 at 11:44 am

Speaking of superbugs…Whatever happened to that 13-year old corpse with a heartbeat in California? Last I heard, she had been moved to a facility of other human Petri dishes.

I had a family member suffer a serious injury. They had to put him on a respirator, and the decline started happening quick. That’s when the nurses told us, wash your hands when you leave. You needn’t bother washing them to come in, because your family member is already full of every bug out there. The family member who was the legal guardian unfortunately took a lot of convincing, and at the end the doctors were practically refusing to enter the room.

106 Willitts September 19, 2014 at 11:44 am

This is not an “Obama plan”. It was a plan developed by the CDC that he took, wrote his name on, and submitted as his own.

Obama is joining the pantheon of personality cult stars Mao, Che, Kim, who were experts at everything and leapt tall buildings in a single bound.

I hear Obama fastroped out of the stealth helicopter and personally shot Osama.

107 dan1111 September 19, 2014 at 11:49 am

Surely everyone who cares about this should want the president toting this as much as possible.

108 msgkings September 19, 2014 at 11:57 am

Some people hate Obama more than they like public health

109 Willitts September 19, 2014 at 4:58 pm

Some people don’t like phonies taking credit for other people’s work no matter what party they are in.

This might have been overlooked if he didn’t have a lengthy history of taking credit for other people’s work — merely pointing fingers and patting backs.

Giving him credit for prioritizing resources is vastly different from giving him credit for the plan.

110 Jan September 19, 2014 at 5:42 pm

Like the health care plan he personally designed with no help whatsoever from members of Congress, staffers and dozens of health care organizations? Stop taking credit! 😉

111 Willitts September 19, 2014 at 11:49 pm

While you are factually correct, I think the GOP did more to lay the ACA at Obama’s feet than his party did. The ACA, like Dodd-Frank, were 20 year old white papers drafted the last time the democrats controlled the House.

I would wager that my teenage daughter knows more about bacteria than Obama. I wouldnt be surprised if my younger daughter knows more.

112 dan1111 September 20, 2014 at 5:34 am

@Willitts, I am no fan of Obama, but who is giving him credit for anything other than prioritizing this? Did Obama claim that he created this report or thought up the idea that this was important?

113 Jan September 20, 2014 at 8:46 am

The President doesn’t personally draw up plans for almost anything. This is no different than any other federal initiative as far as I can tell. Clearly it was in the works for a while. I mainly give his domestic policy staff and agency heads credit for developing this and Obama credit for, as dan111 said, prioritizing. That’s it.

114 msgkings September 19, 2014 at 11:56 am

Mission Accomplished! Amirite?

115 Maximum Liberty September 19, 2014 at 6:05 pm

While the issue is important, the approach seems likely to fail.

The main source of anti-biotic resistance is patients. They come in with a sniffle and want anti-biotics because they believe that anti-biotics fix everything.

Simple solutions more likely to succeed than those proposed are:
1. significantly tax anti-biotics delivered in an out-patient setting (and prohibit insurance from covering the tax and do not cover the tax in Medicare of Medicaid);
2. impose a co-payment on outpatient anti-biotics under Medicare and Medicaid; and
3. require a lab test confirming the presence of a bacteria that is susceptible to the anti-biotic being prescribed before delivering anti-biotics in an out-patient setting.

The lab companies would get behind #3. Docs would get behind #1 or #2.

Max L.

116 Willitts September 19, 2014 at 11:52 pm

I largely agree with you but in my experience, doctors throw antibiotics at patients with viral infections. They claim it is to stop secondary infections from a weakened immune system, but I suspect it is defensive medicine.

117 Rahul September 20, 2014 at 1:11 am

Depends on the patient. If it’s a 65 year old grandma the precaution is quite legit.

118 Richard September 22, 2014 at 5:48 pm

From my experience as a doctor, most of the prescription happens when patients come in asking for an antibiotic. We’re taught to try to convince them that what they have is a viral infection that does not benefit from treatment, but they are insistent that 1. they know their own bodies better, or 2. the HMO is trying to save money, or 3. that the doctor is incompetent.

For the doctor, the choice in practice very easily becomes 1. spend an extra 10-15 minutes convincing/arguing with the patient, refusing to prescribe the antibiotic, falling behind in clinic, and getting low marks on patient satisfaction surveys, or 2. just give in and give them what they want. After all, someone who has just paid $20 copay would much rather have a prescription than mere advice and reassurance.

I’ve noticed that things have gotten worse in this regard since the advent of webmd and internet-based resources. Please let me know how we can change incentive systems given this scenario.

119 akülü istif makinası September 20, 2014 at 8:11 am

akülü istif makinası Lifturk Firmamız Hakkında
Kaldırma ve Taşıma Ekipmanları sektöründe hizmet vermek üzere kurulan firmamız, kurucuların meslek ve bilgi alanları nedeniyle ağırlıklı olarak Kaldırma ve Taşıma Ekipmanları, Çelik Halat, Zincir ve Deniz sektöründe siz değerli müşterilerimizin ihtiyaçlarını karşılamak amacıyla Tuzla ve İmes sanayi bölgelerinde kurulmuştur.

KURULUŞ AMACIMIZ
Ülke çapında kaldırma ve Taşıma Ekipmanları,Çelik Halat, Zincir ve Deniz sektöründe öncü olmak ve liderliği hergün daha da büyüyen bir organizasyonla sürdürmek, Siz müşterilerimizin ihtiyaçlarını, geniş ürün yelpazesine sahip stoklarımızla karşılamak , Fiyat uygunluğu ve dürüst çalışmayı kendisine ilke edinmiş olan firmamız, bölge bayisi olduğumuz, dünya çapındakendini kanıtlamış markaların sanayinin önde gelen firmaları tarafından tercih edilen üstün nitelikli, kaliteli ve sertifikalı ürünlerini tecrübeli personelimiz ile tarafınıza en hızlı şekilde ulaştırılmasında tüm enerjimiz ile çalışmaktır.istif makinası
KALİTE POLİTİKAMIZ
Kaldırma ve Taşıma Ekipmanları,Çelik Halat, Zincir ve Deniz sektöründe müşterilerimizle uluslararası kabul görmüş standartlarda en iyi hizmeti sunarak lider firma olmak, tüm çalışan- larımızla sürekli kalite kavramını çevreci bir anlayış içinde tatbik etmek şirketimizin politikasıdır. zincirli vinçler

120 Nathan W September 20, 2014 at 2:48 pm

In NY I stay in cheap dorms. In other places in the world I get a whole hotel room to myself. Whoo hoo!!

121 Nathan W September 20, 2014 at 2:57 pm

If you’re sick enough to need an antibiotic, you probably need to see a doctor. If you’re not sick enough to go to the doctor, then you probably don’t need an antibiotic.

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