It is something of a horror story. Children are getting sick with a perfectly treatable illness but parents are struggling to get their hands on the right drug — penicillin, no less — and some are dying. People are visiting eight, nine pharmacies and travelling to different cities to fill their prescriptions. The Government says there is no overall shortage in the UK — though there is an export ban — and anyway, that means little to the parents dealing with the sharp end of a local lack of the necessary drugs.
What is happening with Strep A and amoxicillin shows up the fragility of a system we take for granted. There has been plenty of shouting in academic and policy circles about an antibiotic crisis, meaning the rise of deadly antibiotic-resistant bacteria (estimated already to kill nearly 1.3 million people a year). But there’s a second antibiotic crisis which has been creeping up on us for more than a decade: an increasing disruption in the availability of common antibiotics, such as penicillin.
This second crisis has has mostly affected low-income countries, which might account for the lack of attention from rich ones. But now its affecting the rich ones too. In the US some 32 antimicrobial drugs are in short supply. Each time an antibiotic runs out it is an event costing $20-$30 million worldwide, as patients stay longer in hospital or have to rely on expensive substitutes. Mortality rates soar.
What’s the problem? Why are antibiotics more likely to run out than other popular medicines like heart drugs and antidepressants? Well, antibiotics make less money and there’s less of an incentive to keep up with demand. Most antibiotics tend to be ‘generic’ drugs that have been kicking around for years: they are cheap to the point that fewer and fewer suppliers want to provide them. Many of these drugs, therefore, have just one or two suppliers, making it hard to scale up production quickly, say, if lots of children start falling ill.
Plus, the drugs are so cheap and manufacturers operate at such razor-thin margins that there’s no real profit incentive to make sure they can expand to cope with increased demand. There aren’t warehouses with emergency stockpiles of amoxicillin, because these wouldn’t make financial sense.
And shortages in antibiotics don’t just happen when demand rises — they are generally more likely than with some other drugs. Supply chains stretch thin and globally. A disruption anywhere in the process can bring the whole thing to a halt — an earthquake affecting a single factory, say, can wipe out half the world’s supply. In 2016 a fire in a factory producing piperacillin–tazobactam resulted in prolonged worldwide shortages. Added to this, most manufacturers have outsourced production to a few concentrated locations in China and India, making them vulnerable to natural disasters and geopolitical risks.
The long supply chains also make it hard to predict where the next disruption might be coming from. Forecasting systems, when it comes to antibiotic supply, are particularly inaccurate.
And of course, shortages of common antibiotics also risk exacerbating the other, better known antibiotic crisis. If a drug runs short, doctors prescribe not-so-good alternatives, or broad-spectrum ones. That’s a petri dish in which superbugs appear.
It’s clear that the world — particularly the rich world — needs to get a grip on this crisis. Relying on the pharmaceutical industry to sort itself out won’t work: antibiotics simply aren’t money spinners, and big pharma simply isn’t a charity. The funds to invest in new antibiotics and ensure the ones we have are kept in good supply will come from public-sector funding and philanthropic agencies. That means countries co-ordinating to tackle the problem.
At present there is no global consensus on how to manage antibiotic shortages. We need one. There has been much hand-wringing over our various collective failures on Covid-19 — countries should have worked together better. But the next global health crisis is on our doorstep.
It shouldn’t be easy to brush over this crisis. Parents are panicking and children are dying, both here and abroad. A problem we have ignored in third world countries is becoming a first world one. But there’s a risk that in 2022 we are becoming inured to shortages and disaster — even this ongoing tragedy is not quite enough to stir governments into co-ordinated action. It should. The problem of antibiotic shortages is not going away. There will be one after this, and after that.
