PLoS Medicine published an article in their Policy Forum this month, provocatively titled "Do We Need to Put Society First? The Potential for Tragedy in Antimicrobial Resistance", by KR Foster and H Grundmann. The article positions global antibiotic resistance as a proverbial "tragedy of the commons" and the authors propose that the accessibility of antimicrobials results in widespread antibiotic resistance. Although various parties try to curb the overuse of antibiotics by patients, they say, "current policies may only partly solve the problem". As they put it, these efforts:
"do not address the conundrum at the heart of antimicrobial resistance: the solution may ultimately require us to put society before the individual. That is, halting the rise of resistance may only be achievable if some patients go untreated. We defend this uncomfortable conclusion using the logic of the well-known social dilemma "the tragedy of the commons."
So the glut of antibiotics causes antibiotic resistance, which we should solve by restricting antibiotics? Perhaps we should call it: "The Tragedy of the Commoners"? Their stunning conclusion comes in the first paragraph, and is only dwarfed by the photo on the right, of an oozing sore on the dark knee of a person inflicted with methicillin resistant Staphylococcus aureus (MRSA).
As if an afterthought, the next sentence reads: "More data on the societal costs of resistance are required to evaluate the potential for a tragedy of antimicrobial resistance and the moral dilemma that it would present." One would have hoped that the "more data" part would come before the publishing part but perhaps tenuous commentary is the purpose of PLoS's "Policy Forum".
Though the topic sentence may affront the reader, the theme of the article is more or less drug allocation and management, a vital concern to national and international drug and health programs. The proposal PLoS publishes may seem draconian but it is not foreign. Drugs are routinely made unavailable to some people, inadvertently or by design. For instance, various drugs for infectious (and other) diseases can be priced above what many patients can pay. Patents or trade regimes limit drug use and usefulness to allow pharmaceuticals to maximize profit. Governments and businesses hoarding drugs. Recently, governments and corporations identified of subsets of people who will receive Tamiflu (whether it works of not), if and when bird flu becomes epidemic.
So yes, drug production, allocation, distribution, and management are well discussed in public health, policy, and economics circles. Antibiotic resistance is certainly on the rise and problematic. But is the "tragedy of the commons" a useful metaphor to analyze the problem?
Tragedy or Dismal Science?
Garret Hardin's 1968 essay, "The Tragedy of Commons" (available online at Science: Vol. 162. no. 3859, pp. 1243 - 1248 and here), describes how resources in the public domain tend to get overused and depleted. According to Hardin's views which stem from neoclassical economics, private ownership offers individual owners incentive to conserve a resource so as not to detract from its future value. "Common" resources by comparison, offer no such incentive. Therefore individuals tend to overuse "commons" because they only recognize the immediate value of what 'to their mind' seems like an endless resource, whereas any loss of value or burden due to depletion is shared by many other individuals. Therefore for each person, the rewards are greater for taking than for conserving.
Hardin's essay popularized a general phenomena described by Aristotle and others in easy to grasp, simplified terms. It's most frequently applied to environmental problems: fisheries, water resources and pollution, and it may adequately describe these situations where many individuals have access to these resources. The simplicity, popularity and malleability of the parable make it easy to apply to other problems such as internet usage, university education, and public radio.
The parable is also used inappropriately. For instance in a case of asbestos litigation¹. , the lawyer wrote "What we have here is a failure to cooperate", citing a line from "Cool Hand Luke" and meshing that with the tragedy of the commons by advocating curtailing payments to "asbestos plaintiffs,...[who are] arguably 'overgrazing' the accessible financial assets...". Private financial "assets" are not commons and injured plaintiffs looking for compensation for asbestos lung injuries are not "overgrazing.
So while the simple "commons" metaphor can useful, it can also be used for dubious intention to effectively blame individuals for complex societal problems, to erode individual rights, or to promote legislation that privatizes natural resources (even when it is clear that privatization does not necessarily solve common resource problems).
The PLoS authors chose to use the tragedy of the commons parable for the problem of antibiotic resistance based on an article about the Spanish national health care program: "Baquero and Campos recently argued that this dilemma mirrors what Hardin termed "the tragedy of the commons". But if you read the article, you would know that the Spanish authors write specifically about the public health program in Spain where doctors prescribe drugs to patients based on a national formulary. Baquero and Campos outline incentives that could be used for the pharmaceutical companies, doctors, and patients to curb excessive prescription use in the Spanish system.
Although the Spanish case isn't a good example of the "commons", as we'll see below, the PLoS authors seem to discount the Spanish authors' solutions while taking liberty to extend the Hardin parable in a vague way to global public health and antimicrobial resistance: "Protecting the antimicrobial commons, and hence the collective best interest, may require society sometimes to act against an individual patient's best interests. The Spanish authors weren't arguing to limit necessary drugs, only to prevent overuse. There are no "antimicrobial commons", and why come out of the gate acting "against individual patient's best interest"?
To be fair, what the authors try to do, integrate antibiotic resistance and economics and public health via a framework borrowed from the 1960's, isn't an easy feat. Hardin himself warned in an article in Science (vol. 280: May 1, 1998):
"A final word about interdisciplinary work -- do not underestimate its difficulties. The more specialties we try to stitch together, the greater are our opportunities to make mistakes -- and the more numerous are our willing critics."
Though Hardin's original essay gained tremendous popularity, it also attracted criticism both for its methods and subject matter. The original essay addressed the overpopulation "problem". Hardin proposed that the "right to breed" could never be resolved or managed by government and the implications were disastrous. However, history doesn't support the catastrophe he predicted. Population growth was controlled via individual family planning. Virtually all developing countries' populations decreased with development that resulted in better public health, female education and increased wealth. But the "problem" still has it's staunch supporters in Malthusian circles, and Hardin recently said (1998) (Science:162): "The reality that underlies all the necessary curtailments is always the same -- population growth."
The failure of Hardin's predictions about population growth doesn't rule out use of the "commons" framework. It has been applied to great effect for conceptualizing environmental problems. But any model, no matter how popular, needs to be measured against the historical record and applied only with care to contemporary problems.
The authors claim: " Hardin's tragedy of the commons has proved to be a powerful analogy for understanding the problem of protecting the benefit we all receive from public goods". We argue that it is not the best analogy. As privatization has become the norm, the concept of a "common" resource becomes almost anachronistic. In the case of antibiotic resistance, it is neither powerful nor an applicable. There are more powerful models that provide better framework to analyze the problem.
Antibiotics are Private Goods
Different disciplines have different vocabularies for the same phenomena that are equally valid, but in the case of public goods economists can do better then the simple "commons" parable. Economists define "public" goods and distinguish them from from "private" goods. A public "good" benefits society and can counteract a "bad". The definition is refined by considering concepts of "excludability" and "rivalry". Lighthouses are the prototypical public good, with non-excludability and non-rivalry, as is national defense. No one can be excluded from using a lighthouse or public defense, and one person's use does not hamper another persons use. For a non-rivalrous good the marginal cost of consumption is zero -- it doesn't impose on society. Non-excludability of a resource, whether it's a light from a lighthouse, national defense, or a broadcast on public airways, is a requirement for a "public good", as is non-rivalry.
Economists further refine these ideas by distinguishing between pure and impure public goods, and pure and impure private goods. A lecture in a public auditorium is an impure public good. Although many people can listen, each person who listens limits the future number of other people who can listen in the space, and is in this way rivalrous. Ocean fisheries are similarly impure public goods, because they are rivalrous, although people for centuries imagined the oceans as a limitless resource.
Club goods such as health clubs and churches are excludable. All private goods, like clothing and haircuts are both excludable and rivalrous. Such services and manufactured consumer products are considered pure private goods. Medicines are considered private goods, however private medicines can be distributed by public programs - but they're still private goods. Exceptions include world wide polio vaccination program, which could be considered a public good.
This framework is not perfect for determining whether a good is public or private. Close examination of such a complex problem is still difficult, but the framework makes it easier to discern whether a problem has more public features or private. Perhaps in a case of nationalized medicine like Spain, antibiotics are not purely private or public, however from a global perspective, antibiotics are private goods. Antibiotic resistance is a global problem.
Antibiotics are sometimes extremely scarce and sometimes abundant. In rural areas throughout the world people die of simple infections that could be cured by antibiotics. In other places like some cities in Asia, antibiotics are priced at steep discounts and used with utter abandon in combination with various other traditional and allopathic medicines. But in both cases private industry determines the scarcity or glut.
An article written by Steve Stecklow and the late Daniel Pearl, from the Wall Street Journal, August 16, 2001, available
here at essential.org, illustrates the extent to which privatization determines the supply of antibiotics. The article describes the influence of various players in the pharmaceutical industry in India. It details some of the profit incentives of pharmacies (which often stand in for doctors in India). The pharmacists' relationships with pharmaceutical companies become arguably more important than the individual patient. The incentives of the pharmacists influence drug sales and in turn affect the use and misuse of drugs:
"Mr. Patil [a pharmacist] also didn't disguise his motivation for recommending certain brands. 'The ultimate decision is based on what the margins are," he said. For fevers, he usually recommended a generic version of the antibiotic Ciprofloxacin; a recent incentive deal from an Indian manufacturer offered him a 250% profit margin and a chance to win a motorcycle..."
Pharmaceutical companies refuse to develop drugs for markets that can't afford to pay, and pharmaceutical companies supply drugs cheaply when there are surpluses. The ethical quandries with this model abound, but pharmaceutical companies consistently act as rational for-profit private entities.
What Are Our Values? The Commons, Individuals, Life & Economic Costs
Antibiotic resistance could be considered a global public "bad". It hasn't always been seen this way. Doctors in the U.S. have been cognizant of antibiotic resistance for decades and have counseled American patients about conservative use of antibiotics. But they ignored or were ignorant to egregious misuse of antibiotics overseas and for the most part failed to conceive how this might effect the US. Antibiotics are not a global public good because they are privately developed, manufactured, sold and managed according to the profit motives of pharmaceutical companies. Pharmaceutical companies influence politicians to pass laws favoring the sale of drugs. The participation of lawyers and politicians is as instrumental to the problem as the prescribing habits of doctors.
This is not a simple dynamic between some individual herders and a pasture. Antibiotics are not a free resource open for public consumption, but a private product sold to consumers by pharmaceutical companies for profit. Yet surprisingly, the word "pharmaceutical" does not appear in the PLoS article. Neither do the words "industry", "company", or "business". The word "drugs appears twice:
1) "Most worryingly, some bacterial strains are resistant to multiple classes of drugs"
2) "...development of new drugs...comes at considerable economic cost."
It's telling that pharmaceutical companies remain unidentified in the article as playing a role. It's their market! It's also telling that "economic cost" makes the potential solution of research and development of new antibiotics unpalatable to the authors, even when they compare it to the "moral dilemma" of not treating patients.
The authors run through many possible solutions to the problems -- curbing prescriptions for viral infections, limiting antibiotic use in agriculture, government incentives for drug development. But they seem to toss these valid solutions aside because they don't fit the text of Hardin's original 1968 essay. Indeed the authors note at the beginning of their essay:
"What is most important for our discussion, however, is Hardin's key insight that a tragedy of the commons lacks a technical solution, which he defined as 'one that requires a change only in the techniques of the natural sciences, demanding little or nothing in the way of change in human values or ideas of morality.'"
Since their article hinges on Hardin's assertion that there is no "technical solution", it's as though they fixate on an answer that seems most likely to satisfy the 1968 article; the one that most emphatically challenges notions of "human values or ideas of morality." They seem to recognize all the misuses of antimicrobials in exhaustive lists in their essay while at the same time recognizing the international disparities in prescription guidelines, but then they toss these key issues aside in favor of their histrionic proposal that we: "face up to the reality of a tragedy of antimicrobial resistance".
It seems that to these authors, contemplating the loss of individual life is less horrifying than contemplating a change in the paradigm of how antimicrobials are distributed. Similarly, when the U.S. government contemplates climate change, it dismisses any proposal that might alter the economic incentives for the entrenched fossil fuel industries. Have privatization and sustaining business profits become subsumed as "human values", and taken precedence over other "human values" that we used to claim such as individual lives and liberty?
Brave Policy Decisions
It is difficult to take seriously proposals that omit important pieces of the problems they claim to consider and discard solutions that they claim to seek. An obvious snag in the logic of the PLoS author's solution, leaving selected patients untreated, becomes clear when imagining the difficulty of imposing such a broad solution successfully, given their assertion that none of the other smaller scale government solutions they considered seemed to suffice.
The biggest problem with applying the metaphor of the "tragedy of commons" to antimicrobial resistance is that it's too vague and amorphous an analogy. There are more cogent and analytical frameworks for contemplating the problem of antibiotic resistance, and by comparison, the "tragedy of the commons" only invites criticism. At best it seems like cultural shorthand that stands in lazily for a more clear-eyed, rigorous, nuanced delineation of a problem.
Such an analysis might question the contention that individuals are best served by international patent regimes that strong arm countries into limiting development of essential medicines -- a view that the authors endorse. This patent protection purportedly motivates pharmaceutical companies to develop new drugs. But if this were true, than why continue excusing companies from not developing drugs because of "economic cost"? If this "...careful use of patents", did indeed encourage drug development, than why would the profit reinvestment need to be further augmented by "government investment" -- especially when governments already provide the means for basic research upon which most drugs are developed?
We could also question how individuals could possibly be culpable for antibiotic resistance: "every herdsman knows that putting too many cows upon a pasture will eventually destroy it by overgrazing. Who "knows" more? The patient in India who walks into the pharmacy as in the WSJ article, hoping to cure their illness? Or the pharmaceutical company that sells them the drugs? Furthermore, does the right of a company to spare "economic cost", trump the right of an individual to spare his own life with medicine that he pays for either with cash at purchase or with taxes he pays to support national healthcare?
While the authors readily acknowledge many features of the antibiotic resistance dilemma, they do no service in forwarding the notion that individuals should bear the brunt of inefficient antibiotics distribution. For years pharmaceutical companies have propagated antibiotic resistance with greedy business practices like dumping pharmaceuticals into markets where their cheap price practically guarantees overuse. Whether the individual is an MRSA patient in a London hospital, an AIDS patient with an opportunistic infection in South Africa or India, an ill aunt in Spain, or a child with strep throat in the U.S., the individuals with infectious diseases are not plundering the drug supply, nor are they responsible for the problem of antibiotic resistance.
The authors conclude that "difficult choices" are in store that may "require brave policy decisions". If governments enacted policies that sacrificed individual treatment via antibiotics would this really be "brave"? This seems routine, business as usual. However, what if governments chose instead to contemplate aspects of the current for-profit paradigm of pharmaceutical companies, the issue that the article published by PLoS; "Do We Need to Put Society First? The Potential for Tragedy in Antimicrobial Resistance", tries to ignore? Wouldn't that be "brave"?
¹ Francis McGovern; "The Tragedy of The Asbestos Commons", Dec. 2002; Virginia Law Review Vol 88, No. 8.