This post is part 2 of a series on science, politics, and the future. You can also check out Part 1: “Science Denialism and the Future of Humanity.”
More or less on a weekly basis, every serious news outlet delivers a new report about antibiotic resistance. This week’s pertains to a hospital in Windsor. Within my lifetime, there is a fairly decent chance of reaching a point at which universal resistance is so common that antibiotics are basically passé, and at that point, large portions of the Western healthcare system will basically need to be shut down.
I mention this not just because it’s an issue of direct concern in and of itself, but because it’s an important analogy to climate change. The threat posed by climate change is, in the long run, bigger. But the end of antibiotics — if it comes — will come first. The science is (even) more settled. The effects are (even) easier to predict. The solutions will not require wholesale retooling of our economies. Yet so far, Western governments and drug companies have watched the end coming with studied unconcern. Why?
There’s no shortage of quick diagnoses for the problem. Drug companies aren’t spending enough on antibiotic research anymore, we’re told. (And it’s true: only four major drug companies are still actively researching antibiotics.) They’re too busy finding lucrative long-term treatments for chronic diseases instead of focusing on urgently needed cures for acute infections. The medical research tax credit programs (the neoliberal answer) need to be retooled to reward investment in antibiotics. Or maybe (the leftist answer) government needs to take over antibiotic research so that it can be driven effectively with or without profit.
The problem we now face, in a nutshell, is evolution. It’s hard for educated humans to grasp the magnitude of the bacterial life on this planet. In terms of the sheer number of independent life forms, bacteria outnumber animals and plants together by many, many, many orders of magnitude. As you read this, the majority of the living cells in your body are not actually human ones — and that’s true under normal, healthy, uninfected conditions. We multicellular life forms are really just a microbial lab experiment that spun wildly out of control a few hundred million years ago and now delude ourselves into thinking we own the joint.
As we speak, these bacteria are multiplying, mutating, adapting, thriving, all in an inconceivably large, teeming mass. If we say that bacteria divide on average once per hour, which I don’t think is absurd at all (the widely cited figure on pop biology websites is 20 minutes), then in the space of just one month, bacteria go through as many generations as humans have since the invention of agriculture. In the space of a year, they live through about as many generations as the entire history of anatomically modern humans. Since penicillin was released in the 1940s, bacteria have had more than enough time to pass through as many generations as the entire documented history of humanity’s direct hominid ancestors, from the earliest australopithecines to the present.
This observation should give us pause. It should also make us appreciate the scope of the problem. Over the course of maybe half a million generations, we perfected bipedalism, built large brains, and invented language. In the same number of generations, bacteria have — unsurprisingly — built defences against antibiotics.
Against this we have, at least for the moment, a contraption which we call the “free market.” The free market is governed in the abstract by something called economics, which is really just a bastardized derivative of evolutionary theory, dressed up in fancy clothing and presented as an innovative science in its own right.
And here we arrive at the problem. Our pharmaceutical companies are larger, wealthier, and more knowledgeable than any of their counterparts in the history of our species. They should be capable of developing a new generation of effective antibiotics. These antibiotics would eventually be defeated by bacteria just as the previous ones have been, but it would buy us time — time to develop yet another generation, which would be defeated in its turn, and so on. Evolutionary arms races like this can continue indefinitely, or at least until one side or the other cracks under the strain.
Now, at first glance, free market rhetoric dovetails nicely with the theory of evolution. The fittest companies, the best products, will thrive in a competitive environment. If you can build it cheaper, or better, or ideally both, you’ll win. And you’ll keep winning until someone else can come along who can do it even cheaper, or even better, or, again, both at once. And so on. The result, in theory, should be progress towards greater efficiency in the marshalling of scarce resources to secure beneficial ends. Free market supporters denounce government intervention in the markets because they think that political manipulation (“picking the winners”) distorts the competitive cycle and replaces the invisible hand of natural selection with the clumsy bumbling of the government bureaucracy. On its face, this is not actually a bad argument.
The problem is, market competition selects for competitiveness in the market. The market is not only an entirely free-wheeling competition, nor does it select for desired social and political ends. I’m going to flesh out this point in a later post, but for now, the important takeaway is that under competitive conditions, whether it’s nature or the free market, units respond to selection pressures through adaptation. That’s not the same as saying that units improve, or get more efficient, or “better,” except in relation to those specific pressures. If the problems they’re adapting to solve aren’t the ones you think they are, or the ones you want them to be, then the “improvements” may actually look a lot like problems rather than solutions.
Which brings us back to drug companies. The purpose of a drug company is not actually to develop a new and effective drug, any more than the purpose of Google is to build a powerful search engine. The purpose of a drug company, like any company, is to maximize value for shareholders. To that end, the drug company attempts to provide a good which other drug companies don’t provide quite as well, which can be priced at a point that the people who want that good are willing to pay for it. If you’re producing something people don’t want or can’t afford, you’re not going to make any money. In theory, our healthcare system progresses insofar as drug companies invest in research with the goal of responding to market incentives to produce better drugs, and cheaper drugs, and better cheaper drugs.
Note, however, that this is not actually the same thing as developing new drugs with the goal of counteracting new evolutionary adaptations by bacteria. Drug companies have a scarce pool of capital and a wide variety of potential projects they could invest in. They respond rationally by investing their capital in those projects most likely to lead to drugs that people are willing to pay a lot of money for. There is no need to suggest a conspiracy on the part of drug cartels here. There might be such a conspiracy, but there doesn’t need to be. In this case the free market can lead to the same outcome with or without elite rigging, the same way as evolutionary processes can move forward just fine both with and without self-aware, intelligent beings like us.
It follows that, at the end of the day, the only way — and I mean, the only way — to make private companies really want to make new antibiotics is to have very high prices for antibiotics. Prices so high that drug companies decide it’s worth investing in antibiotics instead of in new treatments for chronic diseases, cancer, etc. These prices will have to be high enough to make antibiotics seem like a worthwhile alternative to a new chronic disease or cancer medication, and that doesn’t even mean that the prices will have to be similar. A cancer drug will always have roughly the same level of effectiveness as it did when it was invented, so it can be used until a successor comes along. Antibiotics come with a built-in expiry date, whether a “superior” competitor has arrived on the market or not.
Yet the market is not willing to pay these high prices for antibiotics. In the developed world, we expect our public insurance schemes to pay out tens of thousands of dollars for a new chemotherapy regimen for cancer, but the bureaucrats would balk at paying the same price for a round of antibiotics to treat a urinary tract infection, and so would we, and so would the private insurance companies. It’s inane to expect private drug companies not to act in their own self-interest when that self-interest is a defining feature of the evolutionary process which free markets are supposed to emulate. Drug companies aren’t failing to produce antibiotics; they’re succeeding in pursuing their evolutionary imperative of adaptation and success according to the rules of the market. It follows that there cannot be a market solution to the antibiotic crisis unless and until people become willing to pay tens of thousands of dollars for a course of antibiotics.
This is already canon among critics of the industry, who contend that the whole mess should be hauled into the public sector and run on the basis of effective research rather than efficient marketing. I’m not sure I disagree, although there’s obviously a pretty tenuous assumption that government is capable of conducting effective research either. Our present science minister, who would be running the show if we created a government pharmaceutical lab, holds a view of evolution which could charitably be described as antiquated and goofy. It’s doubtful that Gary Goodyear can or would comprehend the problem, so his capability to oversee the search for a solution is obviously equally dubious.
Ultimately I favour public-sector research anyways, because at least it’s not intrinsically opposed to successful drug research under present conditions. Whether the solution is a government-run lab or targeted grants to private labs, I’m not sure, but the net result is the same: government interventions, not markets alone, must generate the incentives to create the next generation of antibiotics. And the sooner government gets started on that task, the better. Of course, there are good reasons why governments — especially Canadian governments — won’t be doing any such thing. More on that later.Tweet