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Diagnosis: How Capitalism Makes Us Sick

Question: what happens to bacteria when they are exposed more and more often to antibiotics, drugs designed to wipe them out? Answer: they evolve, developing resistant strains. So what happens then to such bacteria if ‘broad-spectrum’ antibiotics are brought in, using a ‘scatter-gun’ approach? Then they evolve to acquire a wider immunity. In time, such bacteria develop strains resistant to almost all drugs available. And importantly, bacteria acquire drug-resistance very fast, far faster than the pharmaceuticals industry can discover and develop new antibiotics:

... the number of new classes of antibiotics developed has fallen from 11 in the first 30 years of the antibiotic era to just two new classes in the past 30 years. Whereas 16 new antibacterial agents were registered to the four years before the launch of ciprofloxacin, this was down to just seven between 1998 and 2002.
THE PHARMACEUTICAL JOURNAL, 16 February 2008

Briefly, this helps to explain in part why more and more hospitals have reported deaths from first MRSA (Multi-Resistant Staphyloccus aureus) and more recently C. difficile (Clostridium difficile). For instance, from March 2005, reported deaths in UK hospitals rose in 12 months by 72%, to over 6000. In the USA also, the number of deaths is serious:

In the USA, MRSA is increasingly identified in otherwise healthy individuals in the community (community associated MRSA). Among 5000+ patients hospitalised with MRSA during 2005, around 1000 dies (1 in 5). Adding hospital and community-acquired infections, it is estimated that nearly 20,000 people died from invasive MRSA in the USA in 2005, more than from HIV/AIDS.

In the UK, the spread of multi-resistant strains like MRSA and C. difficile was helped along its way by government policies: by targets for ‘efficiency’ which mean dangerously high bed-occupancy rates. As one media report told us, often a bed was still warm when a new patient was moved into it. Britain has the highest bed-occupancy rate in Europe (February 2008). Putting new patients into beds only just vacated and moving them around from one ward to another, so as to maximise bed-occupancy rates, helps to spread infection. In such conditions, it is impossible for nursing staff to avoid cross-infection .

So what on earth is meant by ‘efficiency’? To most normal people, it means doing the job well. Hospitals that kill or disable their patients by infecting them with drug-resistant diseases are clearly not being efficient. But bureaucrats and accountants have a different view of what they think of as ‘efficiency’. To them it is all about cutting costs. Likewise with the government’s National Institute for Clinical Excellence (NICE): pharmaceuticals are assessed, not just to see if they are safe and effective but, significantly, to ensure that they are ‘cost-effective’.

Considering just one widely prescribed drug, ciprofloxacin, launched in 1987, the PHARMACEUTICAL JOURNAL noted that it had been very widely used:

In its long life, ciprofloxacin has been prescribed for more than 340 million people worldwide, not to mention those who have bought it over the counter in less regulated markets.

For instance, it had been the drug of choice for those who feared ‘traveller’s diarrhoea’ when holidaying abroad. It had been thought by doctors and the pharmacy industry to be the most effective treatment for E. coli and salmonella infections. It was used on the vast majority of patients with gonorrhoea: “today, about 25 per cent of infected patients in the UK have strains resistant to ciprofloxacin” (ibid.).

Another probable cause of resistance to this once very useful antibiotic was the veterinary use of another, closely related, drug, enrofloxacin, for the “mass treatment of herds to eliminate or minimise an expected outbreak of disease” – i.e. as a routine preventive treatment.

As a result, resistant [strains of] E. coli and salmonella have been selected in animals and poultry that enter the human food chain, and cross resistance among quinolones mean that these [strains] are resistant to ciprofloxacin as well as to enrofloxacin (ibid.).

Like other pharmaceuticals, antibiotics are produced as commodities, with the manufacturers hoping for widespread sales so as to maximise their profits. In 2001, just as Bayer’s patent protection for ciprofloxacin was about to expire in many countries, that drug suddenly got a new lease of life as a new market suddenly opened up. Enter anthrax: remember the US scare with anthrax spores after ‘9/11’?

... ciprofloxacin was soon being stockpiled by governments around the world. Ciprofloxacin manufacturer, Bayer, rapidly scaled up production to meet demand and the renewed profitability of the trusty antibiotic helped to offset problems the company was having after the loss of its cholesterol-lowering drug, cervastatin (ibid.).

The fact is that market competition encourages competing drug companies to maximise their sales, and to compete to expand their markets. Such companies are hardly going to advise farmers or GPs not to overuse antibiotics.

In many countries, antibiotics are widely sold over the counter. Those who buy them are very conscious of the cost, in terms of the money they have spent, but are all too often in the dark about the problems caused by not completing the course of treatment. Ignorance of the problem of drug-resistance developing is therefore worsened when the patient has to spend money to buy these expensive magic pills and potions. All too often, after using the drug for a few days, when the symptoms seem to have gone away, the natural reaction is to put the medicine aside, storing it for possible future use.

One result is that multi-drug-resistant TB (MDR-TB) is now known to exist in 45 countries, with some 40,000 new cases every year (CHANNEL 4 News, 21 March 2008). In a recent lecture (Gresham College, London, 22 November 2007), Costing the Arms Race: Drugs, Super-Bugs and the Appliance of Science, Christopher Dye stated that:

A major worry since 2006 has been the emergence of XDR-TB, extensively drug resistant TB, which is resistant to both first and second line drugs.

As an example of how dangerous this can be, he cited how in a single outbreak of XDR-TB infection, near Durban, South Africa, out of 53 HIV-infected patients, 52 died, half of them within 16 days of the XDR-TB infection.

Even in advanced countries, TB is linked with poor food, poor housing, and homelessness. In short, it is largely caused by poverty. Add to that modern problems caused by drug-resistance, lack of access to proper health facilities, and the running down of once efficient hospitals to increase the accountants’ measure of ‘efficiency’, with high bed-occupancy rates, and the result is a modern plague.

Along with the appearance of drug-resistant strains of bacteria, another problem is the slow rate of development of new classes of antibiotics. In the 1970s only one new class appeared, in the 1980s and 1990s none, and since 2000 just two new classes. In the US, the number of new antibiotics has declined steadily since the 1980s and as these new drugs were not in new classes, they were liable to become ineffective quickly due to cross-infection.

Moreover in capitalism the priority is not medical needs but the possibility of making profits. The economics of developing new drugs is not too encouraging:

The average cost of developing a drug from laboratory to market usually exceeds $500 million... and takes 8-10 years from development to sale. The environment is intensely competitive, with companies trying to recoup investment and profit quickly... A profitable drug will make US $1 billion annually at peak sales. More than 40 companies have merged and consolidated over the past 20 years, so there are now only 8 companies still undertaking antibiotic research and development. Antibiotics are financially less attractive to develop than drugs for other indications because they are generally used for short periods for specific, relatively narrow indications.
[Data compiled by Christopher Dye]

The economics of the industry mean that if and when a new antibiotic is launched, the company that spent years researching it and that has a limited time with patent protection in which to make its profits, is bound to try to maximise its use – even in herd treatment of poultry and cattle. That is how the capitalist production for profit system makes us sick. Christopher Dye argued that:

The evolution of resistance to antibiotics is encouraged by their over-use in populations, animal and human, at sub-therapeutic doses.

Likewise the PHARMACEUTICAL JOURNAL'’s article, on the growing resistance to ciprofloxacin, which quoted from an article by Dr D Livermore:

Cipro was oral, convenient to use and cheap. It’s still useful but its benefits have been eroded because it was used recklessly. Looking at what we are doing now with antibiotic use, I’m not sure that we’ve really learnt our lesson from cipro. History has a way of repeating itself.

The problem is not a particular drug or disease, or the emergence of drug-resistant strains. By itself none of these is the root of the problem. As new drugs are developed, the manufacturers need to maximise their use, to market them as widely as possible so as to make as much profit as possible from them, before their patent protection expires or competitors enter their markets with other new ‘miracle’ drugs

It follows that the “over-use” of such drugs (Dye) and their being used “recklessly” (Livermore) is inevitable, as is the predictable consequence: drug resistance. Both the reckless overuse of new antibiotics and the result, the appearance of new multi-drug resistant strains of bacteria, are the outcome of the competitive capitalist system of production for profit.

The underlying problems are social and economic. Unless and until we can evolve our society into one where drugs and other goods needed are produced, not competitively as commodities, i.e. for profit, but cooperatively, to answer to people’s needs; a society where avoidable, poverty-linked diseases like TB can be countered by good food and good housing: so long must we expect to see “history repeating itself”.

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