On Saturday, my two-year-old daughter developed scarlet fever.
This is a fairly common childhood infection, treatable with antibiotics. But children in the UK, where we live, are getting scarlet fever in unprecedented numbers this year, maybe because of knock-on effects of the covid-19 pandemic’s social isolation measures. Complications from a progression of the same infection, caused by the Group A streptococcus bacterium, have been responsible for 15 deaths of children this year.
The UK has a massive, complex, centralized health system, the National Health Service, which is suffering acute underfunding. But low supplies of antibiotics isn’t just a UK problem. In November, the US Food and Drug Administration announced a shortage of amoxicillin, another common antibiotic used to treat children and adults. Widely used antibiotics and antimicrobials—a broader designation of drugs which include those used to treat viruses, fungi, and parasites—also are running short in France, Germany, Belgium, and Australia.
The inability to get supplies of lifesaving drugs, quickly and in large supply, has long been a problem in poor countries. Now the rich world is feeling the same pain.
“There are many complex reasons behind shortages,” writes Enrico Baraldi, a professor of industrial engineering and management at Uppsala University, Sweden, in a post for the Global Antibiotic Research & Development Partnership. But Baraldi, who works on the wider problem of antibiotic resistance, also identifies a root cause: They are too cheap.
“Most antibiotics are ‘generics’, with the positive effect of several competitors producing them and their prices falling, but they have now fallen to a point where fewer and fewer suppliers want to provide them,” he explains. There isn’t enough incentive for companies to produce the drugs, because, despite their extraordinary usefulness, they don’t make money.
A second layer of the problem is that, in part because they’re not profitable, drug companies have concentrated the manufacturing of generic antibiotics in a few facilities, mostly in China and India.
The drugs’ supply chains are inefficient and fragmented, notes a paper published in BMJ Global Health in November 2021. But the last three years have seen existing supply chain problems proliferate and deepen, while new ones have sprung up, sparked by the global pandemic and, more recently, the Russian invasion of Ukraine.
The war and its effect on energy prices also added costs to the production of everything, drugs included. And in the case of antibiotics, the supply chain issues are being “compounded by weak forecasting systems,” notes the BMJ paper.
Essentially, we’re bad at knowing when we’re going to really need antibiotics, and fast.
It took me most of Monday to get the right drugs to start my daughter’s 10-day course of Phenoxymethyl-penicillin, one of the most common antibiotics prescribed for scarlet fever. This involved phoning and queuing at pharmacies, and tramping through the snow to the doctor three times for prescriptions updated in line with what was available. On my phone, a nursery parents’ Whatsapp group was pinging: more cases of scarlet fever, which is highly infectious, were being diagnosed. Now those parents were beginning their hunts for the right drugs.
But the aggravation and fear are far from the only problem. As Nusrat Shafiq and co-authors point out in the BMJ article, shortages of the right antibiotic for any given condition can lead to inappropriate use of other antibiotics, which contributes to the wider problem of antibiotic resistance. Trained by the enemy they encounter, infection-causing bacteria mutate and no longer respond to the drugs which have long been used to treat them.
Unsurprisingly, there are no quick or easy fixes to the problem.
The BMJ paper lays out a raft of interconnected measures. These include more government oversight of procurement of and payment for generic medicines, which is already being tried in the UK and Sweden; changes to licensing and pricing; more local manufacture of drugs; and better forecasting of global need.
In the UK, however, the government has insisted there is no shortage of antibiotics, while pharma companies are under investigation for potentially huge, sudden price hikes in response to the recent wave of Strep A. On-the-ground experience, and international comparisons, would suggest more governments would do well to face up to a problem that seems to be spreading globally.