Antibiotic Resistance: A Tragedy of the Commons

Why overuse of antibiotics is making them less effective, how this resembles overfishing a shared resource, and what policies can protect them.

Antibiotics transformed medicine, making common infections curable. But bacteria evolve, and overuse of antibiotics speeds the spread of antimicrobial resistance, where drugs stop working.

The scale

A major study published in The Lancet in 2022 estimated that in 2019, around 1.27 million deaths worldwide were directly attributable to bacterial antimicrobial resistance, and nearly 5 million were associated with it. Resistance threatens surgery, cancer treatment and childbirth, which depend on effective antibiotics.

A tragedy of the commons

The effectiveness of antibiotics is a shared resource, like a fishery. Each time someone uses an antibiotic, especially unnecessarily, they slightly increase the chance that bacteria become resistant, harming everyone. But the individual patient, doctor or farmer bears little of that cost. This leads to overuse, a classic tragedy of the commons.

Causes of overuse

Prescribing for viral infections, like colds, where antibiotics do not help.
Over-the-counter sales without prescriptions, common in many countries, including India.
Incomplete courses of treatment.
Agriculture: antibiotics used to promote growth in livestock and poultry.
Poor sanitation and infection control, which spread resistant bacteria.

The innovation problem

Few new antibiotics are being developed. New antibiotics should be used sparingly to preserve their effectiveness, which means low sales, making them unprofitable for drug companies. Economists have proposed pull incentives, such as subscription models where governments pay a fixed annual fee for access to new antibiotics regardless of how much is used. The United Kingdom began such a subscription model in 2022.

India’s response

India’s Red Line campaign marks antibiotic packages with a red line to indicate they should only be sold with a prescription. India has a National Action Plan on antimicrobial resistance, and some states have introduced their own plans. Kerala has taken notable steps to control antibiotic sales.

The unnecessary prescription

A patient with a viral cold asks for antibiotics, and a busy doctor prescribes them to satisfy the patient. The antibiotics do not help the cold, but they expose bacteria in the patient's body to the drug, encouraging resistance. Multiplied across millions of prescriptions, this makes antibiotics less effective for everyone.

Thinking antibiotic use only affects the person taking them

Resistance spreads between people, animals and the environment. Each unnecessary use contributes to a shared problem that can make future infections untreatable.

Key takeaways

Antimicrobial resistance was directly linked to around 1.27 million deaths in 2019.
Antibiotic effectiveness is a shared resource prone to a tragedy of the commons.
Overuse in medicine and farming drives resistance.
Subscription payments and prescription controls like India's Red Line campaign aim to help.