Imagine we have a time machine to take us back to the wondrous 1960s. It was a time when England won its first World Cup, and most importantly, the peak of the ‘golden age’ of antibiotic discovery. By then, more than 20 new classes of antibiotics were marketed [1] and about a half of the drugs commonly used today were discovered [2]. This phase of rapid pipeline expansion and mass production was made possible by the collective efforts of scientists, governments and pharmaceutical companies across the United Kingdom and the United States [3]. In short, it was a time when football came home [4] and antibiotic innovation was well at home.

Fast forward to 2018. England has not (yet) won another World Cup, and we’re faced with an antimicrobial resistance crisis with the antibiotic pipeline running dry and the antibiotic market beyond broken; how times have changed. Whilst there’s practically nothing anyone could do to help England win the World Cup (if Southgate managed to do it then by definition he’d be a god), there’re quite a few tangible solutions out there to stimulate antibiotic innovation, such as increasing research funding (push incentives) and setting up a proper reward for antibiotic development (pull incentives).

An editorial in the latest issue Nature Biotechnology argues that a strong market pull incentive is the “missing piece to the puzzle” that is crucial to “supporting the market after approval”; frustratingly, it’s at the same time a policy instrument that “no one has successfully deployed” [5]. But change is in the air. FDA Commissioner Scott Gottlieb recently proposed a licensing model in which “the acute care institutions that are most likely to prescribe these medicines would pay a fixed licensing fee for access to the drug” like paying for software licences, which would “offer them the right to use a certain number of annual doses” [6]. Kevin Outterson, Executive Director of Carb-X, called this “the most encouraging sign on a US government pull incentive in many a moon” [7].

But what else does it take to restore the antibiotic market and to let innovation come home? In addition to dedicating efforts to implement existing incentives, new ways of thinking to fundamentally reconceptualise the roles and relationships between public and private actors in innovation, value creation and market creation will be vital [8]. The early collective efforts that led to the creation of mass-produced antibiotics is the best example to illustrate the critical role of the state in the innovation process. Now, the state has to take a leading role in market creation and risk taking yet again as the antibiotic market becomes so desperately broken. What, then, should be the implications for the distribution of rewards from innovation and the alignment between innovation and the delivery of public objectives if we apply a new lens to examine the value creation process?

Long is the way and hard, but we have reasons to believe that we don’t have to wait 50-odd years to see the revival of antibiotic innovation. For if we did have to wait that long, we’d probably be dead as dodos from resistant infections well in advance; if we were lucky we might lose just a foot, as illustrated by the Jack Webster story in the latest Corrie episodes [9]. But then no amount of pharmaceutical innovation can possibly salvage the life of an England fan [10], except when football finally does come home…this Sunday perhaps?

[1] Novel classes of antibiotics or more of the same? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3085877/

[2] Where have All the Antibiotics Gone? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095086/

[3] Super bugs: An Arms Race against Bacteria http://www.hup.harvard.edu/catalog.php?isbn=9780674975989

[4] ‘It’s coming home’: the meaning behind the Three Lions lyrics https://www.theguardian.com/football/2018/jul/08/its-coming-home-the-meaning-behind-the-three-lions-lyrics

[5] Wanted: a reward for antibiotic development https://www.nature.com/articles/nbt.4193

[6] Statement from FDA Commissioner Scott Gottlieb, M.D., on FDA’s efforts to foster discovery and development of new tools to fight antimicrobial-resistant infections https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm610503.htm

[7] https://twitter.com/koutterson/status/1006556275109482501

[8] Rethinking Value in Health Innovation: from mystifications towards prescriptions https://www.ucl.ac.uk/bartlett/public-purpose/sites/public-purpose/files/iipp_working_paper_rethinking_value_in_health_innovation_1.pdf

[9] Has Corrie’s Jack Webster fallen victim to a superbug? https://www.telegraph.co.uk/news/2018/07/03/has-coronation-street-character-fallen-victim-superbug/

[10] A matter of life and death: population mortality and football results https://jech.bmj.com/content/57/6/429