Let’s say you were asked to name the greatest health risks facing the planet. Priceton University economist Ramanan Laxminarayan, founder and director of the One Health Trust, would urgently suggest you include anti-microbial resistance near the top of that list.

“We’re really in the middle of a crisis right now,” he tells interview David Edmonds in this Social Science Bites podcast. “Every year, about 5 million people die of infections that are associated with antibiotic resistance — 5 million. That’s nearly twice the number of people who die of HIV, TB and malaria, put together — put together. Antibiotic resistance and associated deaths are the third leading cause of death in the world, after heart disease and stroke. So you’re talking about something that’s really, really big, and this is not in the future. It is right now.”

The underlying problem, simply put, is that humans are squandering perhaps the greatest health innovations in the last century by using antibiotics stupidly, allowing pathogens to develop resistance and thus rendering existing antibiotics worthless.

For the last 30 years and in particular through One Health Trust and as director of the World Health Organization Collaborating Center for Antimicrobial Resistance, Laxminarayan has labored to make both shine a light on anti-microbial resistance and push for policies to address it. This, he tells Edmonds, is a social science problem even more so than a medical science problem – but not the exclusive province of either. “I think one of the failures of economics,” he says, “in some ways, is that we don’t take the trouble to understand the nitty gritty of the actual other field, especially when it deals with health economics or environmental economics.”

In addition to his role as a senior research scholar at Princeton, Laxminarayan is an affiliate professor at the University of Washington, a senior associate at the Johns Hopkins Bloomberg School of Public Health, and a visiting professor at the University of Strathclyde.

To download an MP3 of this podcast, right-click this link and save. The transcript of the conversation appears below.

David Edmonds: Ramanan Laxminarayan is founder and president of the One Health Trust, an organization that researches ways to improve global health, trained as an economist. He’s a leading expert on a huge problem which rarely makes the news: antibiotic resistance. Ramanan Laxminarayan, welcome to Social Science. Bites.

Ramanan Laxminarayan: Thanks for having me.

David Edmonds: We’re talking today about antibiotics and antibacterial resistance. You’re an economist. How did you get into this topic?

Ramanan Laxminarayan: Well, that’s a great question. So, if you think about antibiotic use and the sort of problem that it is, it’s actually very much like an environmental economics problem. It’s like optimal harvesting of trees or optimal harvesting of fish, because every time we use antibiotics, there’s less effectiveness available for someone else, because all use of antibiotics results in selection pressure that creates antibiotic resistance. So in that sense, using antibiotics is very different than using an aspirin or a pain reliever or, you know, a statin, for instance, where any of us using the drug doesn’t have an effect on anyone else; the statin works just as well today as it did 20 years ago, as it will 50 years from now, for any patient now.

That puts it in a very unique category of problems, which are called in economics commons, problems which are like the ozone layer or climate change, individual actions having externalities that affect everyone else. And to me, this is a very useful place for economists to engage. And I think the sources of this problem don’t lie really in medical sciences; they really lie in the social sciences.

David Edmonds: So they don’t lie in the medical sciences. Does that mean that you only need a very limited amount of biological or medical expertise?

Ramanan Laxminarayan: No, quite the contrary, I think you need a fair amount of biological expertise for two reasons. One is to formulate the problem with the degree of specificity and attention to the reality of the problem. So I think that’s essential.

The second is, many of the stakeholders who you want to change their minds are in the biological sciences, and they’re not going to take you seriously if you didn’t know what bacterial names were, or how they spelt, or what resistance levels were, or anything of that sort. And I had to invest a lot of time in that part of things, but it’s been a very enjoyable journey. In fact, I think one of the failures of economics, in some ways, is that we don’t take the trouble to understand the nitty gritty of the actual other field, especially when it deals with health economics or environmental economics, to really understand. For instance, the best fisheries economists that I know, know the mechanics and biology of fish extremely well, and that’s what makes them very good fisheries economists, and I’ve tried to learn from those folks in gathering the expertise know this field well.

David Edmonds: OK, let’s get into antibiotics. Give us some background. These weapons against illness, they’ve been around for less than a century. Is that right?

Ramanan Laxminarayan: Oh, antibiotics have been around since 1942 when the first doses of penicillin were used to treat patients.

David Edmonds: And tell me how effective they’ve been. What kind of impact have they had on global health?

Ramanan Laxminarayan: So much of the reduction in high-income countries in mortality had already happened before antibiotics came in. But for the rest of the world, antibiotics have had a remarkable effect. I think some of the estimates are they probably added six years of life to people around the planet just from being able to fight bacterial infections. So they’ve been very, very key to the extension of human longevity, which one would argue is one of the most impressive things that humans have done in the last 100 years.

David Edmonds: And as a matter of interest, how do they extrapolate the impact of antibiotics from, for example, the impact of clean water?

Ramanan Laxminarayan: Well, you’re looking at variations in clean water, and you can control for the availability of clean water in these kinds of studies. I think the sheer availability of antibiotics has made things which you only read about in fiction literature. You’ve probably heard of scarlet fever. Have you ever heard of scarlet fever?

David Edmonds: I have.

Ramanan Laxminarayan: Now scarlet fever is just gone. You don’t see scarlet fever anywhere on the planet. Do you know anyone who’s had scarlet fever?

David Edmonds: I do not.

Ramanan Laxminarayan: And that is because antibiotics have been used so widely that many infections are just no longer a thing. Now it’s antibiotics along with vaccines that have gotten rid of many infections, but certainly they’ve been very useful. You’ve heard of stomach ulcers, right? People used to think they were caused by stress or by eating spicy food or things like that. Turns out that stomach ulcers were actually caused by a bacteria called Helicobacter pylori. They would do real damage to your gut. But today, with antibiotic treatment, no one ever does any sort of surgery for stomach ulcers. You basically treat with the course of antibiotics, and then you’re done. So there are many ways in which antibiotics have changed our lives.

Now, do you know anyone in your world who’s had a hip replacement or a knee replacement?

David Edmonds: My brother’s had a hip replacement after a skiing accident.

Ramanan Laxminarayan: After a skiing accident! I can bet that all of us, if we live long enough, will have some sort of replacement, some joint replacement. Now, none of these procedures are possible without effective antibiotics, because to be able to open the body up and then keep it free of infection is a remarkable skill, and you can’t just do that no matter how clean or hygienic your intensive care unit is or your operating theater is. So many things that we consider to be modern medicine are possible only with effective antibiotics. [Take] cancer, chemotherapy. Many people who died of cancer say, 50 years ago, no longer die of cancer because the drugs are so good. But even so, the leading cause of death of people with cancer is obviously the disease, the cancer itself, but the second most important cause is a bacterial infection that can’t be treated. So nearly everything that you think of and look around you as being modern medicine, getting a root canal, getting a surgical procedure, getting an organ transplant, you cannot do without effective antibiotics.

David Edmonds: So that’s the extraordinary effect they’ve had on our lives. But we’re now faced with this new problem, anti-microbial resistance. What is that? And how serious is it?

Ramanan Laxminaraya