Remapping Debate has a very, very sobering piece on antibiotic resistance, and what it means for the future of health care. Two graphs sum up the problem. The first shows the rise of antibiotic resistance in various common infections.
The second shows the decline in the approval of new antibiotics.
These are not two trends you want to see moving in opposite directions.
There are a lot of reasons for the decline of new antibiotics–the market incentives are hopelessly misaligned, we’ve already picked a lot of the low-hanging fruit, and we’re using way more antibiotics than we should in both humans and in animals. But anything we do to reduce overusage actually makes the problem of new antibiotic development worse, because it reduces the potential profit. At any rate, there’s no clear way to solve this terrible divergence.
I’ve been talking about this problem for a while, but I’ve mostly thought about things like the ear infections that would have left me deaf before the advent of penicillin, or people dying in childbirth. I didn’t start to understand the radical implications that antibiotic resistance has for health care practice until I read the absolutely gripping Rising Plague, by an infectious disease specialist who points out just how much of modern medicine is dependent on being able to control bacterial infection.
- Without antibiotics, there would be very little elective surgery. Before sulfa drugs, surgery was a very serious business with a high risk that a patient might die of some complicating infection.
- Without antibiotics, forget organ transplants. The immune suppression would almost certainly be fatal in a pretty short time period. HIV would also be more dangerous.
- Without antibiotics, retirements would get shorter again. Before antibiotics, the average 60 year old who caught pneumonia was more likely than not to die of it than not. That’s why they used to call pneumonia the "old man’s friend". Nor is pneumonia the only potential killer.
- Without antibiotics, maternal mortality would be a lot higher. So would mortality from abortions, dramatically. While backalley abortions were horrible, and did kill people up until legalization, the theatrical figures thrown around by the pro-choice movement were mostly due to the lack of antibiotics, not the butchery of the freelance abortionists. Between 1936 and 1960, the number of deaths from abortions seems to have fallen by something between 80-95%. Looking strictly at mortality, you’d probably be much better off getting an illegal abortion with antibiotics than a legal one without.
- Neonates would also be much more likely to succumb to infection, since their immune systems are underdeveloped.
- Chronic infections can lead to various sorts of cancer (H. Pylori, the bacteria that causes ulcers, also causes stomach cancer). These would take more people before they got Alzheimer’s.
- The severely disabled would have much shorter life spans. Without antibiotics, there would be no way to treat the bed sores, or the lung and urinary tract infections that are common for people with limited sensation or mobility.
- Strep and its evil cousins, scarlet and rheumatic fevers, would once again be a major killer and disabler of children.
These are by no means all the problems, only the ones I can think of off the top of my head. What this means for health care costs is a lot more spending on infection–but a lot less spending on everything else. It wouldn’t be crazy to see health care costs heading down if we didn’t have a reliable means of germ control.
Of course, that’s a world in which antibiotics mostly just don’t work–and by the time that happens, if it happens at all, most of us will be dead. What happens in between now and then?
Trickier to say. Infectious mortality will go up, reducing our costs for longer, more expensive diseases–and making people less willing to undergo marginal surgeries.
On the other hand, when the first-line antibiotics fail, the second line means admitting people to the hospital for intravenous antibiotics. This is obviously much more expensive than giving them a pill, even if we make all the doctors take pay cuts and use the awesome monopsony power of the federal government to buy all our antibiotics at a discount. We might be able to worry less about those huge health care costs in 2060–but we might need to worry a lot more about our health care costs in the next twenty or thirty years.
The superbugs have not only gotten bad fast–from "not really an issue" in 1980 to a major problem today–but they seem to be getting badder faster, as they merrily borrow resistance-conferring genes from each other. Researchers now say they’re seeing resistance show up in the lab, before they even put the stuff into people.
Of course, the most worrying thing is not the effect on the budget. It’s the effect on the people. A world without antibiotics is a world of vast suffering and early death.
Update: Commenter jmgalanter notes
Oh, it gets even more depressing. You haven’t even mentioned tuberculosis; the susceptible bacteria is hard enough to treat (6 months of three or four antibiotics). Now imagine multidrug resistant (MDR) or extensively drug resistant (XDR) bacteria. There are now even strains that are resistant against every anti-tuberculous antibiotic out there.
From the Wikipedia entry on TB:
One-third of the world’s current population has been infected with Mycobacterium tuberculosis, and new infections occur at a rate of one per second. About 5-10% of these latent infections will eventually progress to active disease, which, if left untreated, kills more than half of its victims. Annually, 8 million people become ill with tuberculosis, and 2 million people die from the disease worldwide. In the 19th century, tuberculosis killed an estimated one-quarter of the adult population of Europe; and by 1918 one in six deaths in France were still caused by TB. By the late 19th century, 70 to 90% of the urban populations of Europe and North America were infected with M. tuberculosis, and about 40% of working-class deaths in cities were from TB. During the 20th century, tuberculosis killed approximately 100 million people. TB is still one of the most important health problems in the developing world.
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