Ara Darzi, a surgeon, is director of the Institute of Global Health Innovation at Imperial College London and executive chair of the Fleming Initiative, which seeks solutions to antimicrobial resistance.
Every few years, Washington rediscovers that America’s medicine cabinet is dangerously dependent on foreign manufacturing, so Congress holds a hearing and moves on. But antibiotic resistance is the slow-moving crisis beneath that anxiety, and it deserves more than a hearing. It is, by any honest reckoning, a national security threat. Yet the United States is holding at arm’s length the very tools that would blunt it, stalled not by science but by inertia.
Resistant bacteria directly caused about 1.27 million deaths worldwide in 2019 and were associated with 3.7 million more, according to a landmark study in the Lancet — a toll greater than that of HIV/AIDS or malaria. Effective antibiotics are the invisible precondition for much of modern medicine: chemotherapy, transplants, joint replacements, intensive care, safe childbirth. A 2015 study estimated that if the antibiotics used in American surgery and cancer care lost even 30 percent of their effectiveness, the country would see roughly 120,000 additional infections and 6,300 additional deaths a year from those procedures alone.
This is not a distant threat to a few. It is a threat to the floor beneath all of American health care.
It is also a security threat in the literal sense. Secondary bacterial infections are a leading cause of death in viral pandemics; a military cannot treat its wounded without antibiotics; and the supply chain for these drugs runs overwhelmingly through China, which supplies nearly half of the world’s antibiotic ingredients and about 94 percent of the chemical building block from which amoxicillin and its relatives are made. China is, by Washington’s own description, America’s most significant geopolitical challenge.
When the liquid amoxicillin widely prescribed for children ran short in 2022, American parents went from pharmacy to pharmacy trying to find it. That was a market tremor. A geopolitical one would be far worse.
This is what should frustrate anyone who follows global health policy: The U.S. government knows how to respond, but is choosing not to. The core problem is a market failure. Every use of an antibiotic breeds resistance to it, so the newest and best ones must be held in reserve — which means their makers cannot earn back the cost of developing them. Novartis, AstraZeneca, Allergan and Sanofi all quit antibiotic research between 2016 and 2018. Achaogen, a California start-up, won approval for a needed new drug in 2018 but was bankrupt within a year.
The answer, worked out a decade ago by health economists on both sides of the Atlantic, is a subscription: Instead of paying per dose, the government pays a fixed annual fee for unlimited access to a new antibiotic for its own programs — Medicare, Medicaid, the Veterans Health Administration — no matter how much or little it chooses to use. The company can still sell the drug to private insurers and hospitals. The developer gets a predictable baseline return; the health care system can keep its best antibiotics in reserve.
Britain’s National Health Service signed the first such contracts in 2022 and expanded the program in 2024. But Britain is a small market; it cannot move the global pipeline alone. America can.
The U.S. version is the bipartisan Pasteur Act, introduced in 2020 by Sens. Michael Bennet (D-Colorado) and Todd Young (R-Indiana) and reintroduced three times since, most recently in June of this year. The bill would authorize $6 billion over 10 years to fund contracts of up to a decade, paying $75 million to $300 million a year per drug — less than 1 percent of a single year’s U.S. defense budget. It has never reached a floor vote.
There is a second potential U.S. reform, cheaper still and even more neglected: paying for diagnostic tests. Much antibiotic prescribing is guesswork, because the rapid tests that could tell a doctor whether an infection is bacterial — and thus treatable with antibiotics — can cost several hundred dollars and are often not reimbursed by insurers. Few will spend that to decide whether a $5 drug is needed.
So clinicians prescribe as best they can, and as a result roughly a third of outpatient antibiotic prescriptions in this country are unnecessary. The fix: Reimburse the test as readily as the pill, use federal purchasing power to drive the test’s price down, and adopt a simple rule — outside of an emergency, where an affordable rapid test exists, no antibiotic should be prescribed until the test says it is needed.
That would slow resistance while saving money. Diagnostics reform is the highest-leverage intervention available, but it is also the least glamorous, which may be why Washington ignores it.
The rest of the agenda is familiar to anyone who watched the U.S. mobilize to develop covid-19 vaccines: strategic reserves of critical antibiotics and their ingredients; manufacturing diversified across allies and in some cases brought home; real-time global surveillance; and American leadership in the Group of Seven, Group of 20 and World Bank to finance antibiotic innovation as a shared public good, not sporadic charity. The Biden and Trump administrations have both taken initial steps on supply-chain resilience. They are first steps on a long road.
Alexander Fleming warned in 1945 that misusing penicillin would breed the resistance that can destroy it. Nearly a century on, his warning is the world’s reality, and the maddening truth is that the United States is not helpless before it. America has the science, the tools and the money. What it has lacked is the decision to treat one of the defining threats of the century as something more than a footnote. Congress can change that with a bill that has already been written. It should pass it.
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