Today we warmly welcome Alexander Chaitoff and Joshua Niforatos to the blog. They are medical students at the Cleveland Clinic Lerner College of Medicine with interests in social justice and health equity. See the end of this post for their full biographies.
Just earlier this month, news broke that one of the first new classes of antibiotics in quite some time was discovered. Understandably, the news was met with jubilation. But while many are celebrating this breakthrough, some within the public health community are tempering their excitement.
These news reports generally highlight pharmaceutical and technological developments, yet fail to remind the public that infectious diseases are largely considered diseases of the poor. After all, it is easier to rally behind a “miracle” technology than it is to rally behind a restructuring of society that prevents multi-drug resistant diseases in the first place.
The discovery of a new class of antibiotics does as much to highlight the many economic and social issues in our world as it does to kill deadly pathogens.
Skimming through the pages of the history of medicine, the same infectious diseases that once killed the Romans of antiquity were the same infections that killed poor Americans until the early 1900s. Only one hundred years ago, Americans were more likely to die from infectious diseases, tuberculosis and the flu, than they were to die from the chronic diseases that now afflict the country.
However, with the serendipitous discovery of penicillin by Alexander Fleming in 1928, many felt infectious disease would become a thing of the past. As new classes of antibiotics seemed to be in endless supply, the nation’s brightest minds, and biggest wallets, turned their attention towards new health challenges.
Unfortunately, the antibiotic pipeline has dried up and dangerously resistant organisms have started to emerge. Health leaders are again recognizing infectious diseases as a leading problem, which explains the excitement that has surrounded the recent discovery.
Drug development has major limitations for curing infections of poverty.
Consider first that this new drug that has garnered so much excitement has not yet been put through rigorous clinical trials. These trials can cost well over 100 million dollars, and less than 8% of drugs that begin trials are brought to market. This means that unless there is the potential for a hefty profit, pharmaceutical companies steer clear of testing many drugs in development.
Herein lies the problem. It is harder for pharmaceutical companies to recoup an investment in treatments for infectious disease. In this case, it also means that there is still a low likelihood that the antibiotic that made the news last week will be available anytime in the near future.
Just as disconcerting, we’ve seen what happens when a pharmaceutical company decides to get behind a cure for an infectious disease. In 2014, Gilead received approval for the first cure for Hepatitis C, a disease that largely impacts those with less education and living in poverty. However, when Gilead priced their drug regiment at over $80,000, they effectively limited access for the patients with real need.
Even if this new wonder-antibiotic is made available, why should anything different be expected?
The problem goes beyond the economics of drug development. Effective treatment of infectious diseases ranging from Ebola to chikungunya does require an understanding of the science behind new antibiotics. However, and equally important, effective treatment also requires an understanding of what it means for an infection to be a disease of poverty.
The north-south continental poverty divide in the United States.
Holt JB, 2007. Data Source: Community Health Status Indicators.
A 2011 Institute of Medicine report revealed alarming data that the poorest of the poor in the United States are disproportionally affected by a host of infectious diseases that preferentially infect those in low-income and middle-income countries. The groups most likely to be afflicted by neglected infections of poverty include minorities; single-family, low-income households; racially segmented cities; the American South; and other groups that live along the fault lines of society. These fault lines within society have deep historical roots in the power relations of class, gender, and race. Our social institutions – political, economic, cultural, religious, and legal – reinforce these unequal power relations.
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane,”
Martin Luther King, Jr. once noted. Health disparities are also one of the most lethal forms of inequity.
As money is filtered into efforts to create antibiotics for infectious diseases, it is astonishing that money is not equally as filtered into resources dedicated to building a more “just” society. These resources would result in society where diseases of poverty do not disproportionately affect the poor. In commenting on how to treat and prevent the spread of Ebola, for example, infectious disease specialist Paul Farmer notes that,
“the only formula we’ve come up with is the following: you can’t stop Ebola without staff, stuff, space and systems.”
A new class of antibiotics is exciting news, but that feeling must be tempered. Unless the world stumbles upon another golden age of antibiotic discovery, one new antibiotic will only buy us time in the fight against the ever-evolving microbes that surround us.
At this point in history, scientific advancement, while very important, is not the real issue in this fight for health. The real issue is that infectious diseases are diseases of poverty. The real issue is that new antibiotics alone will not save us from these diseases, but social solutions just might.
It is far easier and less expensive to fund research into novel drug discovery than it is to develop a society in which everyone has equal and affordable access to quality care. Perverse incentives can inhibit the organization and funding of a public health system that is able to educate, prevent, and treat infectious diseases that primarily infect the marginalized of society. Such excitement concerning the discovery of a single drug without a willingness to make more difficult investments reveals our failure to truly understand how bacteria and viruses actually work.
Alexander Chaitoff studied microbiology and political science at The Ohio State University before receiving his MPH as a 2013 Marshall Scholar. Interested in the nexus of scientific and social determinants of health, he has worked and researched for a variety of organizations including the Department of Health and Human Services, the National Health Service, and in 2010 co-founded the 501(c)3 nonprofit research organization the Pure Water Access Project, Inc. He is currently a medical student at the Cleveland Clinic Lerner College of Medicine.
Joshua Niforatos is a medical student at Cleveland Clinic Lerner College of Medicine. Prior to attending medical school, he earned bachelor degrees in both cultural anthropology and biology at University of New Mexico. He then went on to earn a Master of Theological Studies at Boston University School of Theology where he studied theology, anthropology, and ritual. Interested in the intersection of liberation theology and social determinants of health, and reflecting on his public health experience working with immigrants at risk for Type II diabetes in New Mexico, he is a co-founder of a student chapter of Physicians for a National Health Program at Case Western Reserve University.
Image source: Holt JB. The topography of poverty in the United States: a spatial analysis using county-level data from the Community Health Status Indicators project. Prev Chronic Dis 2007;4(4). http://www.cdc.gov/pcd/issues/2007/
oct/07_0091.htm. Accessed 21 January, 2015.