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Carolina Flores

A world without antibiotics?

Antibiotics have been a major driving force in the reduction of incidence of infectious diseases, and therefore in the development of living standards all over the world. However, bacteria are capable of adapting and developing resistance to antibiotics in a short time, which means that new drugs are constantly necessary to keep diseases from spreading. In the past few years, in large part due to misuse of antibiotics, the rate at which they become obsolete has greatly increased. This is aggravated by big pharmaceutical companies leaving or radically reducing attempts to discover new drugs to place in the market, and genomic research failing to deliver new products. This is a problem that needs to be tackled on a wide scale, involving cooperation between business, government and research institutions.

Consider for a moment how deep and wide-reaching the consequences of lacking antibiotics would be. Obviously, epidemics would rise and once again kill millions of people, severely impairing any chances of social or economic development. Tuberculosis would again spread (this is particularly worrying: the World Health Organisation estimates that, between 2000 and 2020, it will infect one billion people and kill 35 million). Pneumonia would once more become a common cause of death, particularly amongst older people. Sexually transmitted diseases would become much harder to cure, causing a number of serious health problems including ectopic pregnancies and a rise of infertility. Organ transplants - or even a surgery as commonplace as removing a burst appendix - would become virtually impossible. (Boseley, 2010, 1)

This apocalyptic scenario – returning to the situation we were in during the pre-antibiotics era, only with a much higher population concentrated in smaller spaces, (which facilitates the rise in epidemics) - might not be far away if nothing is done to avert it. In 2004, it was estimated that over 70% of pathogenic bacteria were resistant to at least one of the current available antibiotics. A number of ‘super bugs’ – resistant to most of the clinically used antibiotics – have also emerged. For instance, S.aureus, a bacteria which has developed resistance to methicillin, is estimated by the Infectious Disease Society of America to be responsible for half of the hospital-associated infections, killing 100 000 people a year in USA hospitals alone. (Demain, 2009)

How has this situation come to be? As bacteria evolve and adapt to changes in the environment, it is no surprise that new antibiotics are regularly needed. However, in the last few decades, the pace at which they adapt has become much faster, and ‘super-bugs’, resistant to most antibiotics, have become more common. This is related to misuse of antibiotics driven by economic reasons. Over half of the antibiotics used in the world are not used to cure disease, but in animal feed, because they work as growth promoters and make it possible to avoid the spread of diseases in conditions in which many animals are kept in a small space. (McVeigh, 2012) This means that we are daily being fed with antibiotics – and unaware of this fact.

To aggravate the issue, since the 90s, most of the big pharmaceutical companies have either completely abandoned antibiotic development (for instance, Roche, Merck and Abbott) or significantly cut down their investment in the area. Instead, they have invested in creating drugs for chronic diseases, which, as they need to be taken for extended periods of time, provide a much better revenue stream than antibiotics, used in short treatments. In addition, regulatory requirements for new antibiotics have become much stricter, greatly increasing the cost of their development. In particular, in the clinical trials phase, their patents last a relatively short time, and new drugs are often reserved for special cases. All this has increased the cost of inventing new antibiotics, making it less appealing than it once was from a business perspective. (Ragnar Norby et al., 2005)

It seems then that economic factors and the drive for profit are behind what may come to be a very serious problem worldwide. To avoid collapse in healthcare, we need to act on the causes of the problem.

First of all, it would be important to regulate the use of antibiotics which are medically important to cure human disease as growth promoters in animal feed (McVeigh, 2010), and also to enforce stricter guidelines on prescription. This could potentially slow down the appearance of ‘super-bugs’, but it doesn’t tackle the problem of lack of production of new antibiotics.

To do so, the main players in this problem – big pharmaceutical and small biotechnology companies, governments and hospitals, and research centres and universities - must be targeted. Better communication between them – for instance, cooperation between research groups and pharmaceutical companies to make the production of new antibiotics cheaper and faster – is an important factor. It may also be important to research if the legal requirements for putting new products in the market can be reduced in a way that makes that process cheaper for companies while keeping it safe for patients. (Ragnar Norby et al, 2005)

In the USA, the IDSA has suggested changes in legislation, such as patent extension, and measures such as tax incentives, to encourage the production of new antibiotics. (Ragnar Norby et al, 2005) Others (Boseley, 2010, 2) have suggested that the key step is to reward hospitals and drug companies for what they do to keep antibiotics effective, for instance by taxing drugs to reduce prescription and investing the revenue into the production of new antibiotics.

This is a very complicated issue, for it involves a large number of organisations and economic factors need to be considered in conjunction with human impact. It is clear, however, that this is an urgent problem whose solution will require a global plan involving investment, cooperation, and regulation. Further, it illustrates that the drive for profit found in business must be combined with a serious and responsible consideration of its human and social impact.

BOSELEY; Sarah, 2010. Are You ready for a world without antibiotics?

 The Guardian (online), 12 August 2010 (28th February 2012) 

BOSELEY; Sarah, 2010 (2). A Radical Plan to Save Antibiotics.

 The Guardian (online). 7 September 2010. (28th February 2012) 

DEMAIN, A.L., SANCHEZ, S., 2009. Microbial Drug Discovery – 80 years of progress. The Journal of Antibiotics. 62, 5-16.

McVEIGH, K. 2012. Scientists: Overuse of Antibiotics in Animal Agriculture Endangers Humans The Guardian (online)

, 19 September 2012 (28th February 2012) 

OVERBYE, K.M., BARRETT, J.F., 2005. Antibiotics: Where did we go wrong? Drug Discovery Today, Volume 10, Issue 1, 1 January 2005, Pages 45–52

RAGNAR NORBY, S., NORD, C.E., FINCH, R. for the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), 2005. Lack of Development of New Antimicrobial Drugs: a Potential Serious Threat to Public Health. The Lancet Infectious Diseases, Volume 5, Issue 2

 February 2005, Pages 115–119 Available at: (28th February 2012)

Matt Griffiths

The contagiousness modifier

By Matt Griffiths**,** working Pro Bono for Costello Medical Consulting, and Robert Wiblin

In order to understand the impact of any charitable intervention against a disease, it is imperative to have a full appreciation of the scope of the disease burden, both epidemiologically and economically. By 'scope of the disease burden', I am not only referring to a standard static measurement of the prevalence, treatment costs and morbidity; we also need to factor in the dynamic nature of the disease itself. For instance, imagine a choice between two treatments: programme A, which provides direct treatment to 100,000 sufferers of a poorly transmissible disease, or programme B, which cures just 10,000 patients suffering from a similarly painful disease that is renowned for its high transmissibility. The immediate impact of programme A will be higher, but ultimately programme B may represent the more cost-effective option, especially if further cases are hard to treat.

Without factoring in the contagiousness of a disease, we will probably underestimate the effect that curing someone with a given disease may have. [A] Furthermore, we won't appropriately prioritise highly contagious diseases.

One way of capturing the effect of the contagiousness of a disease on the impact of a cure/treatment might be to develop a quantitative measure unique to each disease, here termed the 

. When I started searching I was hopeful that such a measure would exist amongst the epidemiological literature. The question is, after all, important for prioritising the provision of healthcare. My search was, admittedly, not systematic, but after exploring a number of search terms based around "contagiousness/transmissibility" of disease on Google and PubMed, I was disappointed to find nothing of obvious application to the problem.

I then decided to consider another phrasing of the problem: '

if someone with the disease is spontaneously cured, how many fewer people will catch the disease who otherwise would have?'

 This strongly reminded me of another measure I had heard of: the basic reproductive number, referred to as R

The basic reproductive number is defined as "the average number of secondary infections caused by a single infectious individual during their entire infectious lifetime". R

 must be greater than 1 for a disease to persist in the population. It would certainly seem to be a promising tool for modelling contagiousness of different diseases, not least because this measure is well studied and because indicative values are already documented for a number of diseases (e.g. measles ~12-18

, HIV ~2-5 [among male homosexuals in England and Wales

]). So, can these values be used to directly generate contagiousness multipliers for comparing different diseases, and thereby allow us to determine the effect of a charitable intervention in terms of the total number of disease cases avoided over a given time period?

 is quite an imperfect measure. The basic reproductive number is not a characteristic of the disease alone, but of the disease in a specific population at a specific time. In particular, it is not possible for a disease to indefinitely have an R

 far above 1, because eventually the number of people with the disease would exceed the entire population! There are several ways a disease with a high R

 tends to see its basic reproductive number decline over time:

Someone who already has a disease can't 'double catch' it

Someone who has already had a disease often dies or becomes immune

We, as humans, respond and contain such diseases with artificial interventions.

Over the long run, a disease should reach an equilibrium in which the rate of new cases equals the rate at which people are cured. If this wasn't the case, curing a single person of a disease with a high R

 would have an enormous impact in the long run!

 for a disease in a given time and place, this value would still take some interpretation for our purposes. R

 represents the total number of people who are infected with a disease by a contagious individual, and so describes the value of curing someone before they become infectious. This is therefore a useful number when evaluating interventions for disease prevention, but not treatment. Many charities may not cause people to be treated who otherwise wouldn't have been, but instead may cause them to be treated earlier. In this case what matters is the 'rate of transmission per day', not the total number of people infected. If we know the average length of time that an infected person remains contagious, we can derive this number. [B]

Nonetheless, the factors influencing contagiousness of a pathogen are many and interacting: pathogen and host characteristics as well as overarching population dynamics all play a role, and are likely to differ between diseases. It is not practical for us to consider all of these factors individually and so it seems to me that a contagiousness multiplier must be derived from epidemiological measures that already exist. The basic reproductive number has provided a good starting point, and whilst the caveats associated with the use of R

 limit its direct application as a contagiousness multiplier, the exploration of this tool has certainly highlighted to me some important points for consideration. I hope that in my further research the potential indirect applications of R

[A] At least if we are using micro-level studies, rather than data looking at the prevalence of a disease across an entire region.

[B] A disease with a low probability of transmission, but a long infectious period, might have the same R

 as a highly contagious disease with only a short infectious period, because the R

 values will be calculated over the respective infectious periods of these diseases. As a result, when trying to model the impact of a charitable intervention over a given time period, the direct application of R

 as a contagiousness multiplier is not appropriate.

http://practice.sph.umich.edu/micphp/epicentral/basic_reproduc_rate.php

 Mills CE, Robins JM and Lipsitch M, Transmissibility of 1918 pandemic influenza, 

http://ocw.jhsph.edu/courses/publichealthbiology/PDFs/Lecture2.pdf

Stephanie Crampin

Film Review: "I AM"

On 24th January 2013 I was invited to take part in a discussion panel at the European premiere of the movie documentary “

”, directed by and starring Tom Shadyac.(1) This blog post is intended mainly as a summary of what I thought of the film, but will also describe how I felt being part of its launch.

The film is an account of Tom’s journey around the world, speaking to the ‘significant minds’ of today. He asks them two questions ‘what’s wrong with our world?’ and ‘what can we do about it?’. He receives a wealth of answers, some of which I’ll go over, but the main conclusion was in the spirit of G.K. Chesterton’s response to The Times’ request to write an essay on the topic of “What’s wrong with the world?”: “Dear Sirs, I am. Sincerely yours”.

This is one of my favourite aspects of the film. Tom Shadyac gets to play the flawed protagonist in his own piece. He himself became very wealthy in a short space of time after his first films were a success, so naturally, he ‘went shopping’. This included buying two progressively large mansions, and a whole host of exotic nik naks. After reaching this point he realised that he was not actually much if at all happier than before he was successful, priding family and community values above those of financial and social success.

He decided that a change was needed for the morally better, and gave up a large portion of his wealth, using it to start up a homeless shelter in Virginia, and donating a significant amount to Telluride. He gave up his 17,000-square-foot Mansion in Los Angeles, greatly simplified his life and moved into a trailer park.(2) After a near fatal mountain biking accident in 2007, Tom suffered post concussive stress disorder, and, having almost been killed, claims not wanting to die without having shared his story. This is the purpose of “I AM”.

It covers some topics that resonate strongly with the idea that giving can be a part of someone’s life, and one’s own personal wealth is much less important than we think, once our basic needs are met. It explains the sociological factors behind the attitude that has developed within (certainly British and American) culture that to succeed in life is to succeed on a material and financial level, and that the idea underlying a big part of this attitude is that ‘greed is good’.(3)

We are conditioned to take more than we need and do it en mass as a society, so that it doesn’t even strike us as greedy or decadent, but just normal. What struck a chord for me was the presentation of this attitude in a single line close to the end of the film: “There is a word for something that takes more than it needs. We call it cancer”. I can’t fault the presentation of the problem. Associating greed with disease is something that will likely add a lot of strength to people’s perceptions that an overabundance of material wealth is a morally questionable idea.(4)

This takes us through (more or less) half of the film. The next half, while putting across a message that I think we should all take on board – that helping other people, no matter who and where they are, is a good thing – left me a little more perplexed than inspired.

The idea he gets at is that people are brought up to be self-centred and function as individuals, but are actually more interconnected as a species than we might have believed. Many examples are used to illustrate this. One of the wilder ones was the notion of quantum entanglement being casually introduced, to illustrate the fact that physical distance can make no difference to the close relationship between two such objects as electrons.

One of the most memorable points has Tom Shadyac sat in front of a petri dish of yoghurt with active cultures, with a voltmeter connected to it, registering activity with changes in his emotions (i.e. when he considered calling either his agent, or lawyer). The message to take from this? Nature is such that we are all connected to things as random as yoghurt, in ways that we don’t quite understand. So by extension, humans are connected to each other as a global species, on an emotional and physical level.

There’s a lot to take in here, and I’m fairly sceptical about how much you need it all to want to help other people. The yoghurt experiment was funny to watch, and would make a great attraction at a science fair, but I don’t really need to be told that I or anyone else is on any level connected to yoghurt to think that using my time and money to try to improve the lives of other people is generally a good idea.

The main concern I have though is that despite all this information, and despite the fact that one of the key questions being asked is ‘what can we do about the world’s problems?’ there is very little in the way of calls to action. In fact there are none. The viewer is left with a feeling of wanting to help, but information on how to, and the best way of doing this, is seriously lacking.

This was reflected in the discussion. When Tom was asked what he thinks we should actually do, he replied that he couldn’t tell a person how they could do good, but that we should all engage with the message that he tries to convey: we are conditioned to want a lot of stuff, but ultimately connected to everyone and everything else (even yoghurt). I don’t think this is enough though. It doesn’t leave anyone with any answers, just more questions. What are the worst problems? Who can solve them? What can I do to help?

For someone who sees this and is left with these questions, the best thing that could happen is that they stumble across the Giving What We Can website. We will tell you just how you can do this.

(1) Tom Shadyac is the director of Ace Ventura, The Nutty Professor, and Bruce Almighty. As you can imagine, he is pretty cool.

(2) Despite the humble sounding name, this is in fact the exclusive 

 in Malibu. I think if I ever ended up living anywhere remotely like this place, I would consider myself to have fallen on my feet.

 by Gordon Gekko is referred to in the film.

 that our sense of disgust is causally related to our feelings of moral condemnation.

Giving What We Can

Announcement – the September Internship Programme

Giving What We Can is offering a 2-week internship programme this September in Oxford, and it promises to be a productive and exciting time for all involved! Including us, the organisers. We are looking forward to this get-together with you smart, motivated people out there!

This September, we will welcome 20 to 25 interns who will get involved in Giving What We Can’s activities on all levels. Last year, the interns worked in small teams that transformed our website, helped with the legal side of things in registering GWWC as a charity in the UK and overseas, and conducted research that impacted the ways our members choose to donate 10% of their income.

It’s hard to describe how cool this is without using too many superlatives. But think about it like this: you get to put your knowledge, skills, and deep thoughts to work, and your findings have a direct impact by saving more lives. Talk about meaningful work.

So we are offering an internship that will be a chance for you to make the world better. In fact it will make it a lot better, and measurably so. That is the main idea behind Giving What We Can, and it’s a simple and powerful one.

In addition to doing good, you get to spend two weeks in the rather pretty town of Oxford and to work closely with like-minded people (and nice people, too, if I may say so myself). Giving What We Can is a new and young organisation, just as it is fast-paced and ambitious. We don’t have a daily routine, but rather work on quickly evolving projects that will require your full dedication and all the hidden talents you may have.

Check out the job specification and requirements here

. Most of all, we need you to be motivated, responsible, and so idealistic that you can’t stand still until see your ideas having a tangible impact on the world.

Watch this blog for more information about the internship. We will try to give you a sense of the kind of work you will be doing. As I said, there is no typical day at GWWC, but we will tell you some more about the things last year’s interns did and what they achieved.

Meanwhile, we’re looking forward to reading your application!

Boris Yakubchik

Why I give

What motivates someone to pledge 1%, 10% or even 50% of their income? How does this affect their lives? Here, one of our 'pledgees' Boris, describes in more detail his reasons for giving 50% of his income to charity and how it has affected his life (the short answer is positively!) Later this month, you'll even have the chance to talk about this with Boris directly. Boris will be taking part in Bolder Giving's Bold Conversation on the 21st February, a monthly phone discussion with an extraordinary giver that you can participate in.

I didn't always give 50% to charity and until about five years ago, I gave nothing. During college, I had the immense fortune of learning about Peter Singer and eventually reading his 

. His essay left a long-lasting impression on me, I felt he opened my eyes to something that was clearly true - helping others when it is of so little cost to you is the right thing to do.

Giving was not what my family did, so it was foreign to me to give my credit card number to someone for a service I would never see performed. Nevertheless I felt it was right, and continued to learn more about the issue, reading 

. Giving more was a gentle progression, first joining a pledge to 

, then, realizing how good it felt, giving larger amounts and giving more often. I started doing "

" - I would ask my friends who insisted on giving me a present to donate to a charity of my choice instead; it was slow at first, but it's become a wonderful tradition.

The turning point came when an acquaintance from the Philosophy Department offered to meet up for lunch. We talked about 

 and other exciting topics; a bit into the conversation he asked if I've heard about Giving What We Can (I had) and then said "What do you think about joining?". At the time, he and our colleagues were starting a Giving What We Can chapter at Rutgers and I eagerly joined in.

What excited me most was that the organizations I was now donating my 10% to were cost effective and transparent. Finally, in December 2011 when I started my first full-time job as a high school math teacher, I realized I could give 50% without decreasing my quality of life one bit. Even after all the donations I was earning more than I was when I was just a math tutor. I've never liked wasting money and have always been frugal. Now I simply apply the principle of cost effectiveness not just to my donations, but to my spending. By 

thinking strategically how to spend money

, I get to enjoy a quality of life higher than if I had been spending 100% of my earnings as most people do.. I still get to enjoy restaurants and outings with friends, though we've found that movie nights or potluck at home are more fun. I don't feel I'm missing out; this year my girlfriend and I are going on a road trip across the US.

Giving 50% has been a rewarding experience. The difficulties people said I would face have not materialized. It is astounding to me that I live better than most kings in history: I eat fresher and more varied food, I listen to the world's best music at a press of a button, I have heating, cooling, and internal plumbing in my apartment, and I don't need to worry about being assassinated. It brings me a great deal of satisfaction to know that a significant fraction of my time that I spend at work, I work not to better my life, but to tremendously help thousands of others.

Alex Catlin

Death by Info-graphic?

The Institute for Health and Evaluation at the University of Washington in Seattle recently produced a time-based 

 of the causes of death broken down by cause and area. Even if you’re not a research geek, like me, you can easily spend hours mining the data and each time you look you discover another story, not just about yourself but about where we still have some real work to do both in terms of our focus at home but more importantly in the developing world. While these observations are fascinating and please feel free to feedback your own, I want to broaden the discussion to the rise of this sort of data and what it represents.

The Causes of Death graph is an illustration of the rising phenomenon of graphical representation of vast quantities of data. As is often said: “A picture is worth a thousand words”. With this in mind the appetite for info-graphics, information visualisation software, geo-visualisation and mash-ups continues to grow unabated. Hans Rosling’s development of the 

 Trendalyzer for instance, has offered a new way of looking at correlations of health, economic, and development, and other pertinent human data across all regions of the globe over the last century up until modern day. By doing this, global trends and developments on the ground can be analysed in terms of their direct impact on a number of relevant benchmarks. Rosling himself points out how you can now use the software to identify the huge bump in life expectancy caused by the invention of penicillin. This is something we have all assumed but it garners particular strength when presented graphically.

Will you sink or swim in the sea of data?

This should also be viewed in the context of what has been described as ‘big data’ - the current technological buzzword that encompasses the vast quantity of data both official and user-generated that is being accumulated through the web. For instance in 2011 alone some some 1.8 zettabytes of data will be created, according to a new IDC Digital Universe study, equal to 57.5bn 32GB Apple iPads. This means data volumes are doubling every two years – faster than Moore’s Law. Indeed, many commentators now predict a time when all policy as well as elements of journalism, think wikileaks, will come from the ability to mine and analyse that data in an appropriate way. Does this mean that database engineers will become the new Gods or does it pave the way for a new wave of analytical tools? Either way we are even more at the mercy of the machines.

While presentation of large quantities of data in a single image or graph makes them much more ‘consumable’, relying on them too much comes with a warning. This is particularly true when the data is being used in decision-making processes and particularly in policy-making. Academics have described this aggregation of data as the ‘data iceberg’ (see Jesringhaus amongst others for details on this) where only the top line figures are viewable, while the complex web of information that makes up the aggregated data is hidden. In terms of the QALY data, it appears to highlight areas that would warrant policy or NGO focus but unfortunately on its own offers no explanation of the context, causes or anomalies that have produced this data. With policy-makers’ time particularly precious there is a danger that this kind of aggregated data will be presented as telling the whole picture, ultimately leading to misdirected policy that attempts to affect the results rather than the underlying causes.

However this take nothing away from the power of this tool. Already people are gaining new perspectives on what areas of intervention require investigation. At the same time new data tells previously unknown stories about what people have to be aware of as individuals in terms of their own health. The data also highlights how lucky we are in the West and how much work has got to be done to address the inequalities in death rates between countries, gender and age. The other stunning fact is how many people die of avoidable causes. Surely the provision of clean water and of the basic necessities to all as well as the extension of Western drugs and healthcare globally can make a huge difference in balancing these figures?

A final thought: Looking at the data provides a little window into our own mortality. Ultimately one day we will be at the bottom of this ‘data iceberg’.

Jess Whittlestone

Encourage discussion, not defensiveness

Getting more people behind a cause you care about can be a great way to 

. To do this you need to be able to communicate your ideas in a way that allows people to engage with them fully. But this isn't always easy. Rather than encouraging constructive discussion, presenting new ideas - especially about moral issues - can often spark confrontation.

I know a number of people have found this when talking about the fact they give x% of their income to charity. As soon as the idea is mentioned, rather than really listening, people often respond defensively; giving reasons why they don't do the same or why your suggestion is totally unreasonable. "I can't afford to save money/pay my mortgage and donate too", "You must be getting financial support from elsewhere if you're donating that much!", and similar responses seem common. As soon as these kind of defensive reactions slip in, all hopes of getting your point across are pretty much shattered.

Why is it so hard to communicate new or controversial ideas without provoking confrontation? How can you improve the way you frame your case to encourage discussion, not defensiveness?

The first thing to note is that we mostly have a strong desire, arguably a 

, to believe that we are good, moral people(1). This means that if you present someone with a piece of information which seems to contradict that belief, they're not going to like it very much. Feeling like their own positive self-image is being threatened, people often 

tend to resent, rather than respect, moral behaviour in others

(2). This is down to a phenomenon known as 