
The case for an antibiotics tax - tpatke
http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/13/the-case-for-an-antibiotics-tax/?wprss=rss_ezra-klein&wpisrc=nl_wonk
======
drjesusphd
This is a great idea. The point of a tax is to impose penalties that exist in
real life, but are not part of the original transaction: externalities.
Widespread use of antibiotics has a cost associated with it that must be paid
by someone, and it should be part of the price of antibiotics.

Much like there's a cost associated with income inequality, so we tax the rich
more to supposedly cover that cost. Costs associate with pollution, greenhouse
gases, moral hazard, etc. are all risks and costs that must be mitigated at
the transaction level, otherwise the market fails.

~~~
spacehome
> Much like there's a cost associated with income inequality, so we tax the
> rich more to supposedly cover that cost.

That's a fairly disturbing way to frame progressive taxation. In the other
examples of taxing externalities, we intentionally discourage the behavior by
taxing it. Do you intend to discourage people from becoming rich by taxing it?
Also, it takes both rich and poor to have inequality. Why not tax poor people
more to discourage poverty?

~~~
ihsw
There are some economic/social theories that suggest homelessness is an
adequate and necessary deterrent to poverty.

However, I'm not going to address a flaw in your logic, namely that the only
role of taxation is deterring undesirable behavior.

~~~
Houshalter
>There are some economic/social theories that suggest homelessness is an
adequate and necessary deterrent to poverty.

Is the implication here that if homeless didn't exist, it would actually be ok
to tax/punish poverty? Otherwise why even bring that up?

------
jswinghammer
The basic problem is that one intervention is seeking to fix another. Crop
subsidies are the reason why these antibiotics are so widely used. Farmers are
encouraged to feed animals food they aren't meant to eat which makes them so
sick they need antibiotics to stay alive long enough to be slaughtered.

Just end those crop subsidies and let things take care of themselves. A few
agribusinesses will be pissed but the rest of us will be much better off.

~~~
maerF0x0
Or ban feeding an animal something that is not part of its "natural" diet.
Then we have the fun of debating if cows naturally eat corn and soy. Chickens
will be particularly fun because they historically ate the scraps from the
humans (what we now call "compost" :P), they were the old form of food
recycling.

~~~
fleitz
I'm pretty sure human beings are not "supernatural" beings, therefore
everything that we do including feeding cows stuff that makes them sick is
"natural".

Now if humans are "supernatural" than cows are also "supernatural" because
they've been created by humans. Cows are a product of centuries of human
genetic engineering.

~~~
maerF0x0
You're attempting to be funny by giving the word "natural" too much thought. I
stuck quotes around the term for people like you.

Natural being defined as something their bodies are "designed" (have fun with
that one) to digest.

------
alexeisadeski3
My fellow libertarians:

Milton Friedman, freedomist gadfly, was in favor of government regulation to
protect the population from contagion. The regulation and restriction of
antibiotics falls firmly within even a minimalist state's purview.

In other words, the government has a clearer mandate to restrict antibiotic
use than it has to restrict heroin use.

~~~
Xdes
>Milton Friedman was in favor of government regulation to protect the
population from contagion.

I'm gonna call source since none of the literature I've read from Friedman
holds such a position. If anything the whole prescription drug system should
be abolished and drugs should be marketed directly to consumers.

~~~
alexeisadeski3
I think Milton would agree with you regarding abolishing the prescription drug
system.

The (only?) exception being antibiotics, which contributes to contagion.

Source was an interview which I watched, so... it'll be hard to find.

EDIT: Never count out Google!

"FRIEDMAN There is room for some public health activities to prevent
contagion, such a thing as for example.."

[http://www.hoover.org/multimedia/uncommon-
knowledge/26936](http://www.hoover.org/multimedia/uncommon-knowledge/26936)

~~~
Xdes
>FRIEDMAN There is room for some public health activities to prevent
contagion, such a thing as for example..

And then Friedman gets cut off when he is about to get into the examples.
Knowing Friedman I would assume his examples would consist of incidents that
the the private industries have quite a deal of trouble handling such as a
violent outbreak or an extreme vaccine shortage.

I would not play off Friedman's words to call for regulation, taxation, or any
other restriction of free trade for antibiotics.

~~~
alexeisadeski3
Antibiotics _do_ constitute a violent outbreak, or at least direly threaten to
release one.

~~~
fleitz
An antibiotics tax won't solve anything.

About the only effective thing you can start doing is MSRA wards in hospitals
and a system of rotating antibiotics. Developing new antibiotics would
probably also be a good idea, no idea what the situ looks like there.

~~~
alexeisadeski3
A tax won't solve anything, agreed, unless it's on the order of 10,000% or
more.

Restricting antibiotics (further than they are currently) may or may not help,
but is certainly within the purview of a limited libertarian state.

Restricting most (all?) other medications is not.

~~~
dllthomas
Antibiotics are used in commercial farming because they increase weight. The
tax simply needs to be enough that (weight(antibioticked cow) - weight(non-
antibioticked cow))*(price of beef) < (cost of antibiotics). Maybe that's "on
the order of 10,000% or more", but I'd like to see numbers.

~~~
alexeisadeski3
Antibiotics are overused outside of commercial farming too.

~~~
dllthomas
Yes, but commercial farming is the single largest use of antibiotics. Cutting
out that use would significantly improve things. We should continue to address
other issues (educational campaigns hammering home the fact that antibiotics
do nothing for viruses, and encouraging completion of the full course when you
_are_ taking antibiotics).

------
diego_moita
But how do you fix antibiotics abuse in other countries? Antibiotic resistant
bacteria are spreading a lot faster in Russia, Pakistan, India, South East
Asia and Latin America. And with international tourism growing it is just a
matter of time before it reaches everywhere in the world.

~~~
scotty79
There is not so much problem of antibiotics overuse in poorer countries as
there is a problem of antibiotics misuse. Where antibiotics are expensive
people tend not to take them long enough so they fail to kill bacteria that
were sligtly resistant to the antbiotic and this also contibutes toward
increasing antibiotics resistance.

You could probably do a lot of good by requiring from the pharmaceutical
companies that want to sell antibiotics on american market to ship half of
their production to Russia and such for free. That would increase price of
antibiotics for americans to prevent overuse and make them available in poor
countries to prevent misuse.

------
tippivenus
There are two components to anti-biotic use that are taken together very
harmful. The first as has been amply described by the author is the flat over
use of anti-biotics where they are not needed. The second and perhaps more
relevant human example is that humans tend not to finish their full course of
anti-botics allowing resistant mutations to gain a greater foot hold. Other
than long acting or implanted delivery mechanisms I am not sure that we can
ever really ensure compliance with the full regimen in all patients.

------
esteb_li
I feel that the problems we face with antibiotics is similar to those we face
with oil. It's common knowledge that the two will _disappear_ and there's
people out there fighting to try to protect us and we have a silent majority
going about their business and ignoring all the warning signs. So yeah, tax
'em

------
m-photonic
From what I've heard, in parts of Asia it's common for antibiotics to be sold
over the counter, and a lot of the worst drug-resistant strains come out of
the developing world. It's a much bigger deal than American agriculture, given
the classes of antibiotics involved.

------
jchrisa
Or we could ban giving them to animals

~~~
Millennium
That's too blunt of an instrument, though. Antibiotics still have legitimate
veterinary uses.

A small tax per unit might stand a better chance, though. Something that might
not be onerous at the low quantities one typically buys antibiotics for when
they intend to use it legitimately, but adding up to something prohibitive in
the mass quantities needed for industrial-scale prophylaxis.

------
mekoka
There was recently an interview posted here on HN about the end of antibiotics
([http://www.pbs.org/wgbh/pages/frontline/health-science-
techn...](http://www.pbs.org/wgbh/pages/frontline/health-science-
technology/hunting-the-nightmare-bacteria/dr-arjun-srinivasan-weve-reached-
the-end-of-antibiotics-period/)). In short, the interviewee Dr. Arjun
Srinivasan was pleading for a serious conversation about what to do to further
regulate their usage, because some bacteria are developing increased
resistance to most, if not all, antibiotics available. What's stunning to me
about all these articles is that, after all these alarms have been raised and
as all the people responsible seem to be contemplating solutions to regulate
antibiotic usage, nobody's mentioning alternative methods to fight bacteria.
Following the afore mentioned article one commenter remarked that Dr.
Srinivasan did a great job or spooking us, but there was absolutely no mention
of bacteriophage during the interview, which got me curious. Turns out phage
therapy
([http://en.wikipedia.org/wiki/Phage_therapy](http://en.wikipedia.org/wiki/Phage_therapy))
has been used successfully for close to 100 years in Russia and Georgia.
According to this Wikipedia page
[http://en.wikipedia.org/wiki/Bacteriophage](http://en.wikipedia.org/wiki/Bacteriophage)

    
    
        Phages were discovered to be antibacterial agents and were used in Georgia and the United States during the 1920s and 1930s for treating bacterial infections. They had widespread use, including treatment of soldiers in the Red Army. However, they were abandoned for general use in the West for several reasons:
    
            - Medical trials were carried out, but a basic lack of understanding of phages made these invalid.
            - Phage therapy was seen as untrustworthy, because many of the trials were conducted on totally unrelated diseases such as allergies and viral infections.
            - Antibiotics were discovered and marketed widely. They were easier to make, store and to prescribe.
            - Former Soviet research continued, but publications were mainly in Russian or Georgian languages, and were unavailable internationally for many years.
            - Clinical trials evaluating the antibacterial efficacy of bacteriophage preparations were conducted without proper controls and were methodologically incomplete preventing the formulation of important conclusions.
    
        Their use has continued since the end of the Cold War in Georgia and elsewhere in Central and Eastern Europe.
    

In other words the reason why western countries stopped considering them, and
to some extent continue to shun them, is lack of understanding.

I am wondering then, if we have to have these "serious conversations" about
regulation of antibiotics for the sake of the threat posed by over-
consumption, how serious can it really be if we have to wear blinders and
continue to pretend that what the Russians and Georgians have been doing is
utter sorcery?

~~~
Fomite
It isn't actually a "lack of understanding" \- I was doing research into phage
therapy over a decade ago, and the field has progressed since then.

There are however a number of problems with phage therapy, and this is from
the perspective of someone who _likes_ phage therapy:

\- Phages are usually very bacteria specific, there isn't really a "broad
spectrum" phage. The therapy used in Russia and Georgia is often a bespoke
formulation for each individual patient. This is:

a. Really, really hard for the FDA to approve. b. Expensive as all hell. c.
Involves keeping "banks" of phages around, and creating custom cocktails of
them. This is, as mentioned, expensive as hell, and manpower intensive.

\- Phage therapy is fairly novel in the West, due to some problems in the
early days of phage therapy followed swiftly by the discovery of penicillin.
It's an entirely different method of treatment, which means all the clinical
knowledge doctors currently have is invalid, and has to be relearned. That's
tough.

\- There's no promise a bacteria _has_ a phage associated with it, and
synthetic phages are, at this point, a pretty distant prospect.

\- When bacterial cell walls rupture, they create endotoxins. Endotoxins are
bad - indeed, in the early experiments with phage therapy in the West,
insufficiently pure phage solutions with endotoxins in them were responsible
for some deaths. Right now, phage therapy is most often used in dire cases,
where side effects like that are less of a thing. For a bad case of Strep
throat? There's some serious clinical trials that need to be done.

\- It's a hell of a lot harder to give someone a 14 day course of
bacteriophages to take home than it is a 14 day course of antibiotics.

Phage therapy is a really fascinating field, and I think it has a lot of
potential. But to say we shun them due to a lack of understanding, or acting
like what the Russians and Georgians do is "utter sorcery" ignores a great
deal of the research that takes place here. The real problem is, even while we
struggle with resistance, antibiotics are _profoundly_ superior as a general
purpose drug. The reasons the Russians used them so heavily is because they
had trouble getting antibiotics.

But seriously, "What about phages?" isn't exactly a new idea.

------
cleaver
I've read that the most effective way for the state to control the public's
behaviour is a combination of taxes and subsidies (sorry, don't recall the
source). Simply tax bad behaviour and subsidize good behaviour. Other means
are possible, but less efficient.

The user fee could work, depending on the scale... if it is possible to be
small enough to not deter individual use, but large enough to deter mass use
in agriculture, then it stands a chance.

As an aside, the common practice of municipal hotel taxes never made sense to
me. Wouldn't a city wish to _encourage_ people to visit?

------
JoeAltmaier
Too little, too late. There was a CDC report that the 'age of antibiotics' is
over and there is little point in limiting their use now. Lets move the
conversation on to something productive: what next?

~~~
rwallace
Bollocks. The complete loss of effectiveness of antibiotics is not something
that has already happened; they are still saving lives as I write this post.
It is something that will happen if we don't change our behavior. Whether we
change our behavior quickly enough has still to be decided.

~~~
JoeAltmaier
The opportunity to prevent the creation of antibiotic-resistant diseases is
gone, that is the point. Go ahead and use your antibiotics, and if you are
lucky they will do something.

Its useful to think in more than black and white. But sometimes thresholds are
crossed; the 'prevent the creation of difficult diseases' threshold has been
passed years ago.

------
ronaldx
The primary use-case of antibiotics remains: curing bacterial illnesses.

We should not seek to increase the price of this for the least well-off in
society.

This would potentially have a net negative effect as it allows bacterial
infection to spread, requiring increased antibiotic use.

Besides, a tax on use wouldn't impact upon doctor's behaviour in the desired
way (reduce non-essential use): since the doctor is still making a net profit
from the prescription and it (still) acts as a convenient placebo.

~~~
ImprovedSilence
RTFA. It's a tax for use of antibiotics on livestock, not humans.

~~~
ericcumbee
Which the cost will be passed along to the consumer.

~~~
ronaldx
I'm sorry that you've been downvoted - because you are right.

This is a tax on poor people that won't affect the majority of readers... it
increases the minimum cost of producing meat.

If we can't figure out high-production meat farming then eventually we're
saying that meat should be something only for the wealthy.

~~~
dllthomas
If it's a choice between meat being something only for the wealthy and a
prevalence of untreatable bacteriological infections, I'm going to go with the
former.

------
ihsw
> The agency is asking the makers of animal drugs to voluntarily alter their
> labels so that farmers can no longer buy antibiotics to promote animal
> growth (a fairly common practice).

I was under the impression that growth is secondary to supplementing the
animal's immune system, especially since factory farms are terribly
unsanitary.

~~~
reuven
I think that it's everything together. Basically, giving animals antibiotics
means that you have more animals (and animal weight) which can be sold at
market. If it were more expensive to give antibiotics to the animals, farmers
might rethink the equation, deciding to instead raise more, smaller animals in
more sanitary environments.

Michael Pollan's excellent book, "The Omnivore's Dilemma," describes at great
length the way in which non-factory farms operate, and why he believes they
don't need the same sorts of sanitary rules that the government places on
factory farms. I have no way of knowing whether he's right, but there's
definitely some logic to the claim that antibiotics are addressing the
symptom, rather than the root cause.

------
dllthomas
I think this is clearly a good idea. Tax antibiotics, use the revenues to help
subsidize development of future antibiotics.

------
squozzer
You would think we'd learn by now that when someone proposes a tax to control
behavior, it's not about the behavior, it's about finding a justification to
grab money. For example, the soda tax.

Why not treat them as controlled substances? All you need is a propaganda
campaign a la Barry Bonds, et al.

