Ramanan Laxminarayan on Antibiotic Use
Let’s say you were asked to name the greatest health risks facing the planet. Priceton University economist Ramanan Laxminarayan, founder and director of the One Health Trust, would urgently suggest you include anti-microbial resistance near the top of that list.
“We’re really in the middle of a crisis right now,” he tells interview David Edmonds in this Social Science Bites podcast. “Every year, about 5 million people die of infections that are associated with antibiotic resistance — 5 million. That’s nearly twice the number of people who die of HIV, TB and malaria, put together — put together. Antibiotic resistance and associated deaths are the third leading cause of death in the world, after heart disease and stroke. So you’re talking about something that’s really, really big, and this is not in the future. It is right now.”
The underlying problem, simply put, is that humans are squandering perhaps the greatest health innovations in the last century by using antibiotics stupidly, allowing pathogens to develop resistance and thus rendering existing antibiotics worthless.
For the last 30 years and in particular through One Health Trust and as director of the World Health Organization Collaborating Center for Antimicrobial Resistance, Laxminarayan has labored to make both shine a light on anti-microbial resistance and push for policies to address it. This, he tells Edmonds, is a social science problem even more so than a medical science problem – but not the exclusive province of either. “I think one of the failures of economics,” he says, “in some ways, is that we don’t take the trouble to understand the nitty gritty of the actual other field, especially when it deals with health economics or environmental economics.”
In addition to his role as a senior research scholar at Princeton, Laxminarayan is an affiliate professor at the University of Washington, a senior associate at the Johns Hopkins Bloomberg School of Public Health, and a visiting professor at the University of Strathclyde.
To download an MP3 of this podcast, right-click this link and save. The transcript of the conversation appears below.
David Edmonds: Ramanan Laxminarayan is founder and president of the One Health Trust, an organization that researches ways to improve global health, trained as an economist. He’s a leading expert on a huge problem which rarely makes the news: antibiotic resistance. Ramanan Laxminarayan, welcome to Social Science. Bites.
Ramanan Laxminarayan: Thanks for having me.
David Edmonds: We’re talking today about antibiotics and antibacterial resistance. You’re an economist. How did you get into this topic?
Ramanan Laxminarayan: Well, that’s a great question. So, if you think about antibiotic use and the sort of problem that it is, it’s actually very much like an environmental economics problem. It’s like optimal harvesting of trees or optimal harvesting of fish, because every time we use antibiotics, there’s less effectiveness available for someone else, because all use of antibiotics results in selection pressure that creates antibiotic resistance. So in that sense, using antibiotics is very different than using an aspirin or a pain reliever or, you know, a statin, for instance, where any of us using the drug doesn’t have an effect on anyone else; the statin works just as well today as it did 20 years ago, as it will 50 years from now, for any patient now.
That puts it in a very unique category of problems, which are called in economics commons, problems which are like the ozone layer or climate change, individual actions having externalities that affect everyone else. And to me, this is a very useful place for economists to engage. And I think the sources of this problem don’t lie really in medical sciences; they really lie in the social sciences.
David Edmonds: So they don’t lie in the medical sciences. Does that mean that you only need a very limited amount of biological or medical expertise?
Ramanan Laxminarayan: No, quite the contrary, I think you need a fair amount of biological expertise for two reasons. One is to formulate the problem with the degree of specificity and attention to the reality of the problem. So I think that’s essential.
The second is, many of the stakeholders who you want to change their minds are in the biological sciences, and they’re not going to take you seriously if you didn’t know what bacterial names were, or how they spelt, or what resistance levels were, or anything of that sort. And I had to invest a lot of time in that part of things, but it’s been a very enjoyable journey. In fact, I think one of the failures of economics, in some ways, is that we don’t take the trouble to understand the nitty gritty of the actual other field, especially when it deals with health economics or environmental economics, to really understand. For instance, the best fisheries economists that I know, know the mechanics and biology of fish extremely well, and that’s what makes them very good fisheries economists, and I’ve tried to learn from those folks in gathering the expertise know this field well.
David Edmonds: OK, let’s get into antibiotics. Give us some background. These weapons against illness, they’ve been around for less than a century. Is that right?
Ramanan Laxminarayan: Oh, antibiotics have been around since 1942 when the first doses of penicillin were used to treat patients.
David Edmonds: And tell me how effective they’ve been. What kind of impact have they had on global health?
Ramanan Laxminarayan: So much of the reduction in high-income countries in mortality had already happened before antibiotics came in. But for the rest of the world, antibiotics have had a remarkable effect. I think some of the estimates are they probably added six years of life to people around the planet just from being able to fight bacterial infections. So they’ve been very, very key to the extension of human longevity, which one would argue is one of the most impressive things that humans have done in the last 100 years.
David Edmonds: And as a matter of interest, how do they extrapolate the impact of antibiotics from, for example, the impact of clean water?
Ramanan Laxminarayan: Well, you’re looking at variations in clean water, and you can control for the availability of clean water in these kinds of studies. I think the sheer availability of antibiotics has made things which you only read about in fiction literature. You’ve probably heard of scarlet fever. Have you ever heard of scarlet fever?
David Edmonds: I have.
Ramanan Laxminarayan: Now scarlet fever is just gone. You don’t see scarlet fever anywhere on the planet. Do you know anyone who’s had scarlet fever?
David Edmonds: I do not.
Ramanan Laxminarayan: And that is because antibiotics have been used so widely that many infections are just no longer a thing. Now it’s antibiotics along with vaccines that have gotten rid of many infections, but certainly they’ve been very useful. You’ve heard of stomach ulcers, right? People used to think they were caused by stress or by eating spicy food or things like that. Turns out that stomach ulcers were actually caused by a bacteria called Helicobacter pylori. They would do real damage to your gut. But today, with antibiotic treatment, no one ever does any sort of surgery for stomach ulcers. You basically treat with the course of antibiotics, and then you’re done. So there are many ways in which antibiotics have changed our lives.
Now, do you know anyone in your world who’s had a hip replacement or a knee replacement?
David Edmonds: My brother’s had a hip replacement after a skiing accident.
Ramanan Laxminarayan: After a skiing accident! I can bet that all of us, if we live long enough, will have some sort of replacement, some joint replacement. Now, none of these procedures are possible without effective antibiotics, because to be able to open the body up and then keep it free of infection is a remarkable skill, and you can’t just do that no matter how clean or hygienic your intensive care unit is or your operating theater is. So many things that we consider to be modern medicine are possible only with effective antibiotics. [Take] cancer, chemotherapy. Many people who died of cancer say, 50 years ago, no longer die of cancer because the drugs are so good. But even so, the leading cause of death of people with cancer is obviously the disease, the cancer itself, but the second most important cause is a bacterial infection that can’t be treated. So nearly everything that you think of and look around you as being modern medicine, getting a root canal, getting a surgical procedure, getting an organ transplant, you cannot do without effective antibiotics.
David Edmonds: So that’s the extraordinary effect they’ve had on our lives. But we’re now faced with this new problem, anti-microbial resistance. What is that? And how serious is it?
Ramanan Laxminarayan: So anti-microbial resistance, or just to easier to pronounce antibiotic resistance — the difference is not that meaningful for people are not deep in this field. Antibiotic resistance is really the growing ability of bacteria to evade or escape the effect of the antibiotics.
Now, how do antibiotics actually kill bacteria? It’s pretty easy, mechanical stuff. They either go and destroy the cell wall of the bacteria, or they go inside and they get inside the bacteria and then destroy the bacteria from the inside. They don’t allow it to sort of reproduce. Now, bacteria that have developed resistance essentially fight back by either having an enzyme that neutralizes the antibiotic. (These are called beta-lactamases that neutralize beta lactam antibiotics) Or they have protections on the cell wall, which basically prevent the antibiotic from coming through. Or they have what are called efflux pumps, which literally are these little pumps that are sitting on the inside of the bacteria, pumping the antibiotic out the minute the antibiotic goes inside the bacteria, right? So you can think of a little fort, and the bacteria has evolved to do all the things to make sure it is safe from the antibiotic. And this is happening at scale.
And what is more interesting here is that the genetic material on how to be resistant, if you think of it as a playbook, is shared freely between bacteria. So, they have what are called plasmid — small, little extra bacterial outside of the cell wall, these packets of genetic information that are being passed around, which any bacteria can incorporate if it were to face an antibiotic, and then it knows how to be resistant. So think of this as they’re publishing their own papers. I mean, not quite, but they are essentially sharing knowledge. They are smart, not because of conscious choice or because they have a brain, but only because evolution works that way.
And in the time we’ve had this conversation, Dave, the bacteria have already had, you know, the next generation has already happened. So they are replicating at such a fast rate that any selection pressure that we impose on them changes their way of operating really, really fast. And it’s quite difficult to keep up with them, to be honest.
David Edmonds: But this knowledge you talk about in inverted commas, this knowledge that they gain, they essentially gain it because we’re using so many antibiotics. Is that right?
Ramanan Laxminarayan: Absolutely. So we’re using too many antibiotics. We’re using unnecessary antibiotics. It’s one thing to use an antibiotic when the patient really needs it. It’s another thing to use it because you have a sniffle, just a cold, or because your doctor just wanted to get you out of their office. [There are] many reasons why antibiotics get prescribed. The best estimates are that, say in the United States, more than 50 percent, probably close of 60 percent, of antibiotics are unnecessary. And that number is true in many high-income countries. We are consuming a huge amount of antibiotics.
Antibiotics also are used in animals. In fact, three quarters of the antibiotics used are not used for human medicine. They are simply used for either disease prevention or to improve weight gain in animals, basically poultry and pigs. So we’ve made the choice as a society to say we want slightly cheaper meat, and in exchange, we’ll give you the crown jewels of modern medicine. And we continue to make that trade off, which is utterly baffling, because people can live without slightly cheaper meat, but it’s very hard for us to actually live without antibiotics when we have an infection.
David Edmonds: You talked at the beginning about the problem of the commons. I mean, it’s a classic prisoner’s dilemma, right? Each of us is better off taking antibiotics, but if we all do it, we’re all worse off.
Ramanan Laxminarayan: Actually, it’s not even that. So Dave, what most people don’t realize is that taking antibiotics does create an externality. It creates a problem for other people, but there’s also a cost to ourselves in that the greatest risk of having a resistant infection is really for ourselves. Then it’s for the people around us, our families, our children, our elderly, and then people who are further away. So people take antibiotics with a mistaken notion that they are safe drugs; they are not. I don’t mean to scare people to say they’re not safe in the sense of they will kill you, but there is a side effect of antibiotics, and there are consequences of antibiotic treatment for yourself. And it’s, again, baffling that people consider vaccines to be unsafe, but antibiotics to be safe. It’s quite the opposite. Actually, vaccines are very safe, and antibiotics actually have a lot of side effects. But of course, you know, the average person doesn’t know that.
David Edmonds: You said you don’t want to scare me, but I want you to scare the listener now. What is the impact if we don’t get this right, if we don’t resolve this problem?
Ramanan Laxminarayan: Well, it’s not in the future, it’s in the present. There are currently people in hospitals near you who cannot be treated with any available antibiotic. This is new. We’ve never had this situation before, and when doctors face that problem, they can simply do nothing for you. We’re back in that era prior to having antibiotics, where you have chicken soup and then wait to see if you’re going to get better, and if you do, you do, if you don’t, then you don’t. Now I don’t know about you, but I don’t want to really be in that place, because we used antibiotics stupidly. We can easily, easily try to fix this problem, but it requires us really appreciating the value of antibiotics.
We’re really in the middle of a crisis right now. Every year, about 5 million people die of infections that are associated with antibiotic resistance — 5 million. That’s nearly twice the number of people who die of HIV, TB and malaria, put together — put together. Antibiotic resistance, associated deaths are the third leading cause of death in the world, after heart disease and stroke. So you’re talking about something that’s really, really big, and this is not in the future. It is right now.
David Edmonds: Those are very dramatic statistics, and you’ve already hinted at a couple of fixes. Obviously, eating less meat sounds like one fix, if we can persuade people to do that or to pay more for their meat, using less antibiotics. If we can persuade doctors to prescribe it less, what else?
Ramanan Laxminarayan: I think these two things would make a huge, huge difference for ourselves to consume fewer antibiotics is definitely a choice we can make, but I think it’s in our eating practices where the volume is most significant. In many countries already, antibiotics are no longer used — medically important antibiotics — are no longer used in meat production. It’s true in Europe. Now it’s increasingly true in the United States, but still, too much is used under the guise of disease prevention, and so we could be using far fewer antibiotics. We could also be spending money to innovate new antibiotics, and we don’t do nearly enough of that. The pipeline for new antibiotics is in pretty bad shape.
We think of this as a problem that’s in the future, but if it’s you or your loved one that’s in a hospital with an infection, that the susceptibility report comes back as resistant, resistant, resistant to all the antibiotics that there is, then it’s too late to try to go find a new antibiotic that point in time, because it takes 15-20, years to get from where we are to new antibiotics.
David Edmonds: It sounds like a kind of arms race. We’re developing new drugs. They’re trying to develop resistance, and if we can slow down our use of antibiotics, we can win that arms race.
Ramanan Laxminarayan: Well, I don’t even think we want to win the arms race. We just want to achieve some sort of equilibrium with the bacteria where, you know, we’ve really slowed it down to the point where we use the antibiotics only when we really are going to save lives and for very specific reasons. One of the mistakes we’ve made is in calling for a “fight” against bacteria. You know, you hear this, the “war” on superbugs, the “war” on bacteria. That’s the stupidest thing I’ve ever heard, because bacteria made life possible for us on the planet. They arrived here three and a half billion years ago, the big oxygenation event. They created the oxygen. In fact, even today, half the oxygen that we breathe does not come from trees. It comes from bacteria. Bacteria are literally essential for every part of human existence, and to think that we can fight bacteria, forget about winning a fight against bacteria, is utterly laughable.
I think our relationship to bacteria has to be one which is a lot more informed. So when I see people with, you know, disinfectants and cleaners, and says, “kills 99.99 percent of bacteria,” I’m like, Why do you want to kill 99.99 percent of bacteria? In fact, you can’t. The average human being has nearly 10 times the number of bacterial cells as there are human cells. You and I, my friend, are mostly bacteria.
David Edmonds: OK, I better start seeing bacteria as my friend, not my enemy. I’m wondering whether your message is getting through. There’s not a war against bacteria, you say, but there are plenty of wars going on at the moment. There’s wars in Ukraine and in Gaza, but 5 million people dying every year because of this problem? Are policy makers listening to you? Are you able to convince people that this should be a priority?
Ramanan Laxminarayan: Policy makers don’t make decisions in a vacuum. They look at data, but they also look at what people are saying to them, their electorate is saying to them. So yes, they’re concerned. This has been the subject of a couple of high-level meetings in the United Nations. The World Health Organization has called this one of the most serious threats to human health. Governments are at least thinking about it, but the urgency with which they will solve a problem depends entirely on, it’s sad to say, the fear factor that the public brings to the table. Now in the United States, I don’t know if you remember this, one case of Ebola — one case of Ebola entering the country — resulted in a $4 billion investment in countermeasures against Ebola for one person, and that person didn’t even actually die. I’m not saying Ebola is not important to fight, but I don’t think public health priorities are determined on the basis of logic or thought process, especially less so these days, with the way public policy is being made, which is utterly stupid. The more we get away from relying on expertise and thinking that every individual is an expert, then, you know, unless you know a lot about antibiotic resistance, good luck.
David Edmonds: I’m wondering what the social science skills are that are needed here, because you’re an economist and you’ve crunched the numbers and you’ve seen the problem. But as you say, it’s difficult to persuade people just with logic, emotion can be more effective and fear can be very effective. Have you thought about messaging rather than just analysis and diagnosis of the problem?
Ramanan Laxminarayan: Absolutely, and I think that’s why I often make the point that taking antibiotics inappropriately harms you first and foremost, before it starts harming other people, in the hope that people would realize that taking antibiotics inappropriately is not a good idea, and they’re not like the safe drugs that people seem to think that they are. That’s number one.
Number two is prevention. There are many ways in which you can prevent the need for antibiotics. If you had better water sanitation, if you had better vaccination, better infection control in hospitals. So, there’s a lot of things that we as individuals can do in terms of just not needing the antibiotics at all in the first place.
The third is, of course, choices on meat consumption, which is a tough message. I remember, we’ve published this so many times, and one time in an interview with a BBC, the interviewer was like, “Well, are you suggesting that people should become vegetarian?” I said, “No, but you have to remember that 50 years ago, people used to eat meat, maybe one day a week, not every meal.” And I think it’s unsustainable to eat meat every meal. In fact, it’s not even good for you. So there are many reasons why we need to reexamine eating meat in the way that we do in the same way that we need to reexamine driving SUVs. I think driving an SUV is fine, but if you’re going to drive the SUV all day round, then that creates problems for the planet through climate change, and that’s the same thing with antibiotic use and resistance, which is we’ve got to be mindful of the effect that we’re having on everyone else, especially people in poor countries.
I think that there’s ways of messaging this without even having to resort to fear. To be honest, Dave, I’m hopeful that that is really what’s going to win the day. If we have to wait for fear, then we’re already too far gone.
David Edmonds: Well, I wish you luck with the messaging, with the campaign, with persuading people to do what’s necessary to reduce this problem. Ramanan Laxminarayan, thank you very much indeed.
Ramanan Laxminarayan: Well, thanks for having me.
