This is a writeup of a shallow investigation, a brief look at an area that we use to decide how to prioritize further research.
In a nutshell
- What is the problem? Antibiotic resistance is developing more quickly than new antibiotics, causing a significant public health threat.
- What are possible interventions? A philanthropist could fund advocacy, research, or public education aimed at the development of new antibiotics or the stewardship of existing antibiotic resources.
- Who else is working on it? The U.S. federal government devotes significant resources to addressing antibiotic resistance and a few non-governmental organizations advocate for further action. We do not have an estimate of the total resources devoted to the issue by different players.
1. What is the problem?
Antibiotic resistance is now evolving faster than new antibiotics are being developed, with the result that antibiotic resistance is a significant and growing public health threat.1 The pipeline of new antibiotics is limited both because much of the “low-hanging fruit” has already been picked (i.e. antibiotics that are easy to discover have already been developed) and because antibiotics are less profitable for drug companies to develop than other drugs.2
Some experts have suggested that without major changes, we will face a “post-antibiotic era,” in which many medical technologies taken for granted in the developed world are no longer available.3 Our understanding is that the loss of antibiotics would have extremely negative effects in terms of morbidity and mortality, but would not eliminate most of the 20th century’s significant medical progress.4 Unfortunately, we are not aware of any systematic assessments of the likely global morbidity or mortality impacts of such a scenario.
2. What are possible interventions?
There are a variety of approaches that may be open to philanthropists aiming to confront the risks of antibiotic resistance. For instance, a philanthropist could back advocacy to the U.S. government to fund more research on new antibiotics, improve the pace of new antibiotic development by reducing the burden of evidence required for some types of use or extending the duration of intellectual property exclusivity on new antibiotics, or impose restrictions on the widespread use of antibiotics in farm animals.5 Philanthropists could also fund, or support advocacy for the U.S. government to fund, research into unconventional antibacterials, such as modified plasmids, that may be able to treat antibiotic-resistant infections.6
Another approach would be to fund advocacy to or education of doctors and the public to encourage appropriate stewardship of antibiotic resources.7 Philanthropists could also fund general public health measures that may limit the spread of antibiotic resistant bacteria, such as vaccination and good hygiene, or fund research on new antibiotics or approaches to treating antibiotic resistant pathogens.8
We do not have a strong sense of the likely costs or benefits of any of these approaches.
3. Who else is working on this?
The United States federal government devotes considerable resources to confronting the threat of antibiotic resistance.
The Interagency Task Force on Antimicrobial Resistance, co-chaired by the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and National Institutes of Health (NIH), coordinates the U.S. response. Each of these agencies does significant work related to antibiotic resistance:
- In 2007, the most recent year for which we could find data, the NIH’s National Institute of Allergy and Infectious Diseases (NIAID) spent more than $200 million/year on “understanding the causes, consequences, and treatments of antimicrobial drug resistance.”9 In 2013, the NIAID launched a new clinical research network to do research on antibiotic resistance, which could receive as much as $62 million over several years.10
- The CDC does not have a single budget line for antibiotic resistance work, which is spread out across four of its eight national centers.11
- The FDA recently established an accelerated pathway for the approval of new antibiotics, with the goal of reducing barriers to their development.12
There is funding for research on and control of antibiotic resistant pathogens in the EU and possibly in other countries, though we have not thoroughly investigated this issue.13 In addition to governments, our understanding is that some for-profit biotechnology and pharmaceutical companies are investing in the development of new antibiotics, though we do not have a sense of the magnitude of this investment. Some non-governmental organizations working to address the issue of antibiotic resistance in the U.S. include:
- The Infectious Diseases Society of America, an association of healthcare professionals who work on infectious diseases14
- Pew Charitable Trusts, which conducts a variety of activities, including advocacy, related to antibiotic resistance15
- The Alliance for the Prudent Use of Antibiotics, a nonprofit that “conduct[s] research, education and advocacy programs to control antimicrobial resistance and ensure access to effective antibiotics.”16
- Keep Antibiotics Working, “a coalition of health, consumer, agricultural, environmental, humane and other advocacy groups” which advocates against overuse of antibiotics in animal agriculture.17
We do not have a full accounting of the resources devoted to these NGO efforts, but we believe them to be relatively limited.
4. Questions for further investigation
Our research in this area has been relatively limited, and many important questions remain unanswered by our investigation. Amongst other topics, further research on this cause might address:
- What drug companies are currently working on developing novel antibiotics, with what results?
- What are the likely humanitarian impacts of further development of antibiotic resistance, and what is the timeline for potential responses? For instance, in the event that the U.S. government decided to devote significantly more resources to addressing antibiotic resistance because of a perceived emergency, how long would research on new antibiotics take to yield clinical results?
- Is there a practical limit on how many new antibiotics remain to be discovered? Our understanding is that many antibiotics in current use are derived from naturally occurring compounds, and future antibiotics may be more difficult to discover than the ones that have already been identified.
- What are the costs and benefits of various philanthropic efforts to address antibiotic resistance, such as particular advocacy approaches?
- What are the resources already devoted to this area by philanthropists and foundations? We are aware of several NGOs working to address these problems, but do not have a very precise sense of the resources that they control.
5. Our process
We decided to investigate this area because of claims that the development of antibiotic resistance could prompt a return to pre-antibiotic levels of mortality. Our investigation to date has been rather cursory.
We spoke with three groups with knowledge of the field, including:
- Steve Solomon and Jean Patel of the Centers for Disease Control and Prevention and the Interagency Task Force on Antimicrobial Resistance.18
- Allan Coukell and Nicole Mahoney of the Pew Charitable Trusts.19
In addition to these conversations, we also reviewed a number of documents, most notably those produced by the Infectious Diseases Society of America.
|Alliance for the Prudent Use of Antibiotics, “Homepage”||Source (archive)|
|Centers for Disease Control and Prevention 1999||Source (archive)|
|Infectious Diseases Society of America 2011||Source (archive)|
|Infectious Diseases Society of America, “Antibiotic Resistance”||Source (archive)|
|Keep Antibiotics Working, “Homepage”||Source (archive)|
|NIH 2013||Source (archive)|
|Notes from a conversation with Allan Coukell and Nicole Mahoney of the Pew Charitable Trusts, 7/17/2013||Source|
|Notes from a conversation with Steve Solomon and Jean Patel of the Centers for Disease Control and Prevention, 6/18/2013||Source|
|Peters et al. 2008||Source (archive)|
|Rice 2008||Source (archive)|
|Roe 2011||Source (archive)|
|Speech by Dr. Margaret Chan, Director-General of the World Health Organization, 03/14/2012||Source (archive)|
|Spellberg et al. 2008||Source (archive)|