Tragedy of the (Antibiotic) Commons: A true market failure

Dear All,

In a 28 Feb 2024 newsletter entitled “How Economists (And Finance Ministers) Think…”, we reviewed an important new paper on the economics of antibiotics from Anthony McDonnell and his colleagues at CGD (Center for Global Development). The paper’s core theme was that the antibiotic market represents a set of market failures which collectively converge as a common pool problem, aka The Tragedy of the Commons (TOTC) or, for our purposes, TOTAC: The Tragedy of the Antibiotic Commons.

Coined in 1968 by Garrett Hardin in his essay in Science entitled “The Tragedy of the Commons: The population problem has no technical solution; it requires a fundamental extension in morality,” TOTC built on the recognized problem of over-grazing of cattle on shared public land (aka, “the commons” in English villages). In its most general form, TOTC is the idea that unrestricted access to a finite resource will lead to its overuse and destruction. Everyone is motivated to use as much as they want, self-restraint just leaves more for others, and no one has a motivation to care for the resource. (As a general resource, the Wikipedia article on TOTC is very good.)

The elegant idea from the paper by Anthony & colleagues is that they reduce TOTC/TOTAC to an AMR-related picture in which diverse antibiotics (the finite resource) are shown as a pool that is fed by R&D (e.g., CARB-X) and then drained as antibiotic use creates antibiotic resistance (AMR):

To dig a bit further into this, I was able to visit with Anthony to have him talk through the ideas in the paper. My frequent collaborator Kevin Outterson came along for the discussion and the result is this 35-minute tour of the ideas of TOTAC:

The deck used in the talk is available here:

Please make time for this one! Anthony’s tour of the ideas is excellent as are Kevin’s builds. As a bonus, we close with a discussion of how TOTC/TOTAC underpins the economics of Pride & Prejudice (yes, Jane Austen!) based on the idea of future interest holders from the Statute of Gloucester enacted in English law in 1278!

And as another new idea (as if linking to P&P weren’t enough), we also discuss the concept of government intervention to support pharmaceuticals (e.g., the PASTEUR Act) is not at all unusual … the Orphan Drug Act of 1983 and the National Childhood Vaccine Injury Act of 1986 both represent interventions that were needed to ensure products were developed and sustained in the market. PASTEUR addresses a specific problem but the principle of (sometimes) needing government intervention is not new. Indeed, the whole point is that true market failures are intractable without government intervention … despite the common mantra, not all government intervention is a bad thing!

Extraordinary! Most of us aren’t economists, but moving the needle on reimbursement for new antibiotics requires the we collectively speak the language of economics. TOTAC and related phrases are actually quite easy to use and explain!

Happy listening! With thanks to all who are putting their blood, sweat, and tears into addressing the problem of antibiotic availablity, –jr

John H. Rex, MD | Chief Medical Officer, F2G Ltd. | Operating Partner, Advent Life Sciences. Follow me on Twitter: @JohnRex_NewAbx. See past newsletters and subscribe for the future: All opinions are my own.

John’s Top Recurring Meetings

Virtual meetings are easy to attend, but regular attendance at annual in-person events is the key to building your network and gaining deeper insight. My personal favorites for such in-person meetings are below. Of particular value for developers are the AMR Conference and the ASM-ESCMID conference. Hope to see you there!

  • 6-7 Mar 2024 (Basel, Switzerland): The 8th AMR Conference 2024. Go here to register! Now past for 2024; will update with 2025 dates when available.
  • 27-30 April 2024 (Barcelona, Spain): 34th ECCMID, the annual meeting of the European Society for Clinical Microbiology and Infectious Diseases. Go here for details. 
  • 17-20 Sep 2024 (Porto, Portugal): ASM/ESCMID Joint Conference on Drug Development to Meet the Challenge of Antimicrobial Resistance. Go here for the meeting’s general website. You can’t register (yet) for the 2024 event, but save the date!
  • 16-20 Oct 2024 (Los Angeles, USA): IDWeek 2024, the annual meeting of the Infectious Diseases Society of America. Save the date! More details to come!

Upcoming meetings of interest to the AMR community:

  • 20 Mar 2024 (virtual, 12.00-13.30 CET): WHO-sponsored webinar on the WHO Medically Important Antimicrobial List (WHO MIA List) that was updated on 11 Feb 2024 (previously, this known as the WHO Critically Important List for Human Medicine). Go here to register.
  • 25-26 Mar 2024 (In person, London): “Novel Diagnostics for Infectious Diseases,” a 2-day workshop co-organised and funded by Imperial College London’s Institute of InfectionJPIAMR-funded B2B2B NetworkLondon In Vitro Diagnostics Co-operativeNIHR Imperial Biomedical Research Centre, and DIAMONDS consortium. Go here for details and to register.
  • 10-11 Apr 2024 (virtual): Sepsis Alliance AMR Conference, a 2-day conference focused on “practical technologies to manage sepsis and counteract the expanding challenge of antimicrobial resistance.” Go here for details and to register.
  • 26 Apr 2024 (Barcelona, Spain): ESCMID workshop entitled “Using Data Science and Machine Learning for Infection Science: A Hands-on Introduction.” Click here to register or here for more details. 
  • 27-30 April 2024 (Barcelona, Spain): 34th ECCMID, the annual meeting of the European Society for Clinical Microbiology and Infectious Diseases. See Recurring Meetings list, above.
  • 26-31 May 2024 (Montreal, Canada): EDAR7, the McGill AMR Centre’s 7th edition of their Environmental Dimension of Antimicrobial Resistance conference. Go here for details; final abstract deadline is 21 Dec 2023.
  • 28-29 May 2024 (in person, Uppsala, Sweden): Uppsala Antibiotic Days, a broad-ranging 2-day program hosted by the Uppsala Antibiotic Center. Go here for details and to register.
  • 9-13 June 2024 (in person, Ascona, Switzerland): “New Approaches to Combat Antibiotic-Resistant Bacteria, 2nd Edition” is a Sunday-Thursday residential workshop focused on the deep biology of AMR. Sponsored by NCCR AntiResist (a Swiss National Science Foundation consortium), the scientific program has the feel of a Gordon Conference. Space is limited, so you are encouraged to apply promptly — go here for details.
  • 13-17 June 2024 (Atlanta, Georgia): ASM Microbe, the annual meeting of the American Society for Microbiology. You can’t register yet, but you can go here for general details.
  • 17-20 Sep 2024 (Porto, Portugal): ASM/ESCMID Joint Conference on Drug Development to Meet the Challenge of Antimicrobial Resistance. See Recurring Meetings list, above.
  • 16-20 Oct 2024 (Los Angeles, USA): IDWeek 2024, the annual meeting of the Infectious Diseases Society of America. See Recurring Meetings list, above. 
  • 19-27 Oct 2024 (Annecy, France, residential in-person program): ICARe (Interdisciplinary Course on Antibiotics and Resistance). Now in its 8th year, Patrice Courvalin directs the program with the support of an all-star scientific committee and faculty. The resulting soup-to-nuts training covers all aspects of antimicrobials, is very intense, and routinely gets rave reviews! Seating is limited, so mark your calendars now if you are interested. Applications open in March 2024 — go here for more details.
  • 4-5 Dec 2024 (in person, Washington, DC): “Fungal Dx 2024: Fungal Diagnostics in Clinical Practice” is a 2-day in-person workshop organized by ISHAM‘s Fungal Diagnostics Working Group. The program and registration links are available at; the agenda is comprehensive and features an all-star global list of speakers.


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