Review

The challenge of antimicrobial resistance: What economics can contribute

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Science  05 Apr 2019:
Vol. 364, Issue 6435, eaau4679
DOI: 10.1126/science.aau4679

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  • RE: The need to explore the economics of (inter)nationalising the antibiotic pipeline
    • Andrew C Singer, Senior Scientist, NERC Centre for Ecology & Hydrology
    • Other Contributors:
      • Claas Kirchhelle, Research Associate, Oxford Martin School/ Wellcome Unit for the History of Medicine, Oxford
      • Adam P Roberts, Senior Lecturer, Liverpool School of Tropical Medicine

    In “The challenge of antimicrobial resistance: What economics can contribute” Roope et al review the role economics can play in tackling AMR (1). A broad review of current strategies is important given the dwindling stock of effective treatments. The bankruptcy of antibiotic developer Achaogen is a clear sign that merely providing ‘pull’ incentives for commercial development with market entry rewards and public-private initiatives is not refilling the antibiotic pipeline (2).

    Roope et al. come to a similar conclusion but warn that private antibiotic investment currently remains unattractive. According to the authors, a “critical aspect” of antibiotic development has to be that it “needs to be profitable regardless of prices and sales volume.” But is this really the case? Does investment in a global commons good really have to be profitable to private entities? And would an overdue, holistic cost-benefit assessment of stalled antibiotic development not clearly highlight the long-term benefits of public reinvestment in non-commercial development?

    In a recent article, we propose a novel way forward which is worthy of further discussion. Drawing on historical examples of successful state-driven antimicrobial development, we challenge the logic of narrowly incentivising proprietary drug development and call for public ownership of both antibiotic research and development (2, 3). Public ownership could easily be achieved by pooling already substantial national ant...

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    Competing Interests: None declared.
  • In reply to Prof Dominic Moran’s eLetter “RE: Managing antimicrobial resistance: the contribution of economics”
    • Laurence S. J. Roope, Senior Researcher, University of Oxford
    • Other Contributors:
      • Richard D. Smith, Professor of Health Economics, University of Exeter
      • Koen B. Pouwels, Senior Researcher, University of Oxford
      • James Buchanan, Senior Researcher, University of Oxford
      • Lucy Abel, Health Economist, University of Oxford
      • Peter Eibich, Deputy Head, Research Group on Labor Demography, Max Planck Institute for Demographic Research
      • Christopher C. Butler, Professor of Primary Care, University of Oxford
      • Pui San Tan, Postdoctoral Researcher, Karolinska Institutet
      • A. Sarah Walker, Professor of Medical Statistics and Epidemiology, University of Oxford
      • Julie V. Robotham, Senior Health Economist / Mathematical Modeller, Public Health England
      • Sarah Wordsworth, Associate Professor, University of Oxford

    In our Review (1), we advocated setting targets for reducing antibiotic-use. Moran proposes a role for marginal-abatement-cost-curves (MACC), sometimes used to rank the relative costs of interventions to reduce CO2-emissions. Moran argues that MACCs could assist AMR priority-setting by illuminating the relative costs of mitigating antibiotic-use in different sectors, e.g. humans versus animals. We agree that MACC-based approaches are worth exploring. However, we would highlight some AMR-specific challenges to using MACCs, beyond the well-documented challenges in the climate-policy context (2). In comparing two interventions A and B for reducing CO2-emissions, a MACC graphically depicts the respective costs of A and B for reducing a ton of CO2, and the number of tons of CO2 the interventions would each reduce. However, as highlighted in our Review, there is no fully satisfactory common unit of antibiotic quantity in the way that there is for a ton of carbon. Antibiotics differ in the extent, and type, of resistance they contribute to, with varied clinical implications. A convincing common unit, in terms of antibiotic-use or AMR, would need to be developed before MACCs could go beyond comparing quite limited sets of interventions. It would also be important that MACCs for ranking antibiotic-conservation interventions capture health and broader welfare costs (and benefits) from reduced antibiotic use. Ultimately, developing convincing MACCs may prove little easier, and less i...

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    Competing Interests: None declared.
  • RE: Managing antimicrobial resistance: the contribution of economics
    • Dominic Moran, Professor of Agricultural & Resource Economics, THE UNIVERSITY OF EDINBURGH

    Roope et al., Science 364, 41 consider the similar challenges and possible links between antimicrobial resistance (AMR) and managing greenhouse gas (GHG) emissions, highlighting uncertainties that handicap valuation of future damages, and the absence of any metric similar to the carbon price to facilitate cost-benefit analysis (CBA) of AMR. They conclude that it may be preferable to set targets for antimicrobial use rather than waiting for information that might improve CBA. It is a curious oversight that they do not then explore how such targets (or caps) have been developed in the context of climate mitigation policy, nor implications of a similar approach for economists considering the AMR challenge.
    Conceptualised as diffuse pollutants, AMR and GHGs share similar properties. A decade ago, there was much uncertainty around GHG abatement measures, and a limited sense of the relative cost of avoiding a tonne of carbon dioxide equivalent emission. To advance policy, some governments developed a rational approach to the problem using marginal abatement cost curves based on environmental economics and the theory of optimal pollution abatement. These ranked cost competitive interventions, and, by facilitating comparison of marginal abatement costs across sectors, they provided a basis for estimating sector specific carbon budgets (1). We are currently in a similar position with AMR and apparently know little about the relative costs of mitigating AM use across huma...

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    Competing Interests: None declared.

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