Wednesday, July 15, 2020

The economics of antibiotics

Penicillin changed the world, it gave us a weapon against disease causing bacteria. Other antibiotics followed. But then evolution changed bacteria--natural selection in an antibiotic rich environment helped them become drug resistant.  Today, the bacteria are sometimes winning--there are some drug resistant bacteria that seem able to resist all available antibiotics. But drug discovery of antibiotics is slowing. What's going on?

Drugs (including antibiotics) are expensive to develop, test for safety and effectiveness, and bring to market.  Part of the problem is that there isn't likely to be a big market for a new super antibiotic. The reason is that, if it is oversubscribed, it will stop being super--bacteria will become resistant.  So a new super antibiotic would be used sparingly, as a drug of last resort.  That's another way of saying that it wouldn't have big sales.

The NY Times has a story:

Drug Giants Create Fund to Bolster Struggling Antibiotic Start-Ups
"New medicines are desperately needed to treat a growing number of drug-resistant infections, but many companies developing the drugs are short on cash and investments."
By Andrew Jacobs, July 9, 2020

"Twenty of the world’s largest pharmaceutical companies on Thursday announced the creation of a $1 billion fund to buoy financially strapped biotech start-ups that are developing new antibiotics to treat the mounting number of drug-resistant infections responsible for hundreds of thousands of deaths each year.

"The fund, created in partnership with the World Health Organization and financed by drug behemoths that include Roche, Merck, and Johnson & Johnson, will offer a short-term but desperately needed lifeline for some of the three dozen small antibiotic companies, many of them based in the United States, that have been struggling to draw investment amid a collapsing antibiotics industry.
"“Antibiotics are the mortar that holds the entire health care system together,” said David A. Ricks, the chief executive of Eli Lilly, who helped spearhead the effort. “We make drugs for diabetes, cancer and immunological conditions, but you couldn’t treat any of them without effective antibiotics.”

"In an interview, Mr. Ricks said he was well aware of the irony that Eli Lilly and many of the other companies contributing to the fund were once the giants of antibiotic development but have long since abandoned the field because of their inability to earn money on the drugs. “We know firsthand how broken the system is,” he said.

"The crisis stems from the peculiar economics and biochemical quirks of drugs that kill bacteria and fungi. The more often antimicrobial drugs are used, the more likely they are to lose their efficacy as pathogens survive and mutate. Efforts to promote antibiotic stewardship mean that new drugs are used as a last resort, limiting the ability of companies to earn back the billions of dollars it can take to create a new product.
"Between 1980 and 2009, the Food and Drug Administration approved 61 new antibiotics for systemic use; over the past decade that number has shrunk to 15, and a third of the companies behind those medicines have since gone belly up.  Those backing the fund acknowledge that the effort is largely a stopgap measure. Industry executives and public health experts say that fixing the broken marketplace for antibiotics would require sweeping government intervention to create financial incentives for drug companies, including policy changes that would increase reimbursements for lifesaving drugs kept under lock and key and used only when existing therapies fail."

Tuesday, July 14, 2020

Polyamorous domestic partnerships recognized in Somerville, MA

Do people in plural relationships have a different sexual orientation than others (and should maybe be protected by laws prohibiting discrimination based on sexual orientation?)  Are they a different model of marriage (akin to, albeit potentially much more complicated than, same sex marriage?)

Here's the story from the online Somerville Wicked Local ("Wicked" is Massachusetts slang, as in the phrase "wicked good").  Maybe this will be the beginning of something (or the beginning of the end of something...).

Somerville recognizes polyamorous domestic partnerships
By Julia Taliesin  Jul 1, 2020

"The Somerville City Council unanimously approved an ordinance with language inclusive to polyamorous domestic partnerships.

"On June 29, Somerville quietly became one of the first cities in the nation – if not the first – to recognize polyamorous domestic partnerships.

"The historic move was a result of a few subtle language shifts. For example, instead of being defined as an “entity formed by two persons,” Somerville’s ordinance defines a domestic partnership as an “entity formed by people,” replaces “he and she” with “they,” replaces “both” with “all,” and contains other inclusive language.

"On June 25, the City Council passed the ordinance recognizing domestic partnerships unanimously, and on June 29 Mayor Joe Curtatone signed it into municipal law. "

Monday, July 13, 2020

More on plasma, payments, and convalescent plasma

Peter Jaworski gives some more reasons that countries should legalize compensation to plasma donors, rather than buying their plasma products from the U.S.

In Reason:
Americans Get Paid To Donate Plasma. Everyone Else Should Too
Our secret weapon against COVID-19 could be cold, hard cash.  7.2.2020

"American dominance in the plasma market is explained by one simple fact: In America, it is legal and commonplace to pay people to give plasma. Millions of Americans regularly give plasma in exchange for $30 to $50 per donation. The average American donor gives 21.4 times per year, with a per capita collection volume of 113 liters of plasma per 1,000 people. If you add plasma obtained from Germany, Austria, Hungary, and Czechia—the other places where a form of compensation (typically capped at 25 euros, intended only to cover expenses) is offered—paid plasma accounts for a staggering 89 percent of all the plasma used to make plasma therapies for the whole world. Just five countries account for nine-tenths of the world's plasma.
"Donor recruitment and retention, staffing, plus marketing costs, combine to make the collection of unpaid plasma two to four times more expensive than just giving money to the donors.
"[bans on payment were partly] motivated by the concern that payment attracted people from lower socioeconomic rungs of the economic ladder who are more likely to be carriers of HIV, hepatitis C, and other transfusion-transmissible infections.

"But those concerns no longer apply, partly due to significant improvements in testing technology since the 1970s when the WHO first recommended not paying blood and plasma donors. This improvement in testing happens to form the backbone of arguments among advocates of eliminating restrictions on blood and plasma donation by gay men, which currently require three months of celibacy per the Food and Drug Administration's revised guidance issued this April. But improvements in testing alone are not the reason why plasma for plasma therapies should be considered categorically different from blood and plasma used for transfusions; it is manufacturers' ability to use virus removal and inactivation techniques that marks the stark difference.

"In the 1980s, we discovered that heat treatment was effective against HIV. Much like how washing your hands with soap destroys the coronavirus, use of solvents and detergents are effective against lipid-enveloped viruses, including hepatitis C and HIV. Nanofiltration ensures that only molecules of a certain size—the proteins we want—get through, preventing larger molecules from passing into the plasma pool. Most American paid plasma collection centers are also International Quality Plasma Program (IQPP) certified. This voluntary standard, issued by the Plasma Protein Therapeutics Association, involves additional safety steps including the requirement that any donor's first donation be placed on hold, only to be released with the second donation from the same donor. This holding step gives us an opportunity to test the same plasma twice, avoiding the rare possibility of a virus being within the window period where it cannot be detected. This hold means that if you give plasma once and don't go back, your plasma will be discarded."

With convalescent plasma donation,  the safety check involved in sequestering the first donation until the second one is also tested for infection is not the only set of tests.  For each donation there is also a measurement of how much Covid-19 antibody (IgG) is present, and if it is enough to be therapeutic. So, for example, after each donation I have to wait for those results to find out if I'll be invited to donate again. (So far, at each visit I give a bit over 800ml of plasma, and that donation is divided into four units of 200ml. My understanding is that my units have so far all been administered to hospitalized Covid-19 patients in Fresno and San Jose.)

Sunday, July 12, 2020

Incorporating patient preferences into transplant decisions can improve welfare--Genie, Nicolo and Pasini in J Health Economics

The role of heterogeneity of patients’ preferences in kidney transplantation
by Mesfin G.GenieaeAntonio Nicol√≥bcGiacomo Pasini
Journal of Health Economics
Volume 72, July 2020, 102331

Abstract: We elicit time and risk preferences for kidney transplantation from the entire population of patients of the largest Italian transplant centre using a discrete choice experiment (DCE). We measure patients’ willingness-to-wait (WTW) for receiving a kidney with one-year longer expected graft survival, or a low risk of complication. Using a mixed logit in WTW-space model, we find heterogeneity in patients’ preferences. Our model allows WTW to vary with patients’ age and duration of dialysis. The results suggest that WTW correlates with age and duration of dialysis, and that accounting for patients’ preferences in the design of kidney allocation protocols could increase their welfare. The implication for transplant practice is that eliciting patients’ preferences could help in the allocation of “non-ideal” kidneys.

Saturday, July 11, 2020

Economics and Computation 2020 updated program, July 13-16

Scott Kominers forwards this update on the EC conference program, including a shortcut to identify those sessions on market design.

Economics and Computation 2020
The main programming of EC 2020, the leading scientific conference on advances in theory, empirics, and applications at the interface of economics and computation, will be held next week from July 13 to July 16.  The program features invited speakers, a highlight of papers from other conferences and journals, a technical program of paper presentations and posters, workshops, tutorials, and ample opportunities for casual interactions and networking. The conference will be run virtually on the Gather platform, an innovative 2D world that facilitates spontaneous small-group conversations. 

Participation by members of related fields is strongly encouraged.  Registration is mandatory (register here) but complimentary with ACM/SIGecom membership of $10 ($5 for students).  Details on joining events will be emailed to registered participants.

All events are listed on this Google calendar.  Paper sessions are broken down by areas of interest in the Google calendars below.  You can add these calendars to your personal Google calendar by clicking the “+Google” button on the bottom right.

4.     Mechanism Design

Unanswered questions about EC’20 can be directed to the Conference Hosts at

Friday, July 10, 2020

Blockchain economics, by Catalini and Gans; and Halaburda, Haeringer, Gans and Gandal

Some Simple Economics of the Blockchain
By Christian Catalini and Joshua S. Gans
Communications of the ACM, July 2020, Vol. 63 No. 7, Pages 80-90

"we rely on economic theory to explain how two key costs affected by blockchain technology—the cost of verification of state, and the cost of networking—change the types of transactions that can be supported in the economy. These costs have implications for the design and efficiency of digital platforms, and open opportunities for new approaches to data ownership, privacy, and licensing; monetization of digital content; auctions and reputation systems."

The Microeconomics of Cryptocurrencies
Hanna Halaburda, Guillaume Haeringer, Joshua S. Gans, Neil Gandal
NBER Working Paper No. 27477  July 2020

Abstract: Since its launch in 2009 much has been written about Bitcoin, cryptocurrencies and blockchains. While the discussions initially took place mostly on blogs and other popular media, we now are witnessing the emergence of a growing body of rigorous academic research on these topics. By the nature of the phenomenon analyzed, this research spans many academic disciplines including macroeconomics, law and economics and computer science. This survey focuses on the microeconomics of cryptocurrencies themselves. What drives their supply, demand, trading price and competition amongst them. This literature has been emerging over the past decade and the purpose of this paper is to summarize its main findings so as to establish a base upon which future research can be conducted.

Thursday, July 9, 2020

Safe injection sites: surreptitious harm reduction, in the NEJM

When healthcare interventions must be conducted secretly, it's likely that something is very wrong with the law.

A letter in the New England Journal of Medicine brings us up to date on safe injection sites, to combat deaths from drug overdoses.

by Alex H. Kral, Ph.D., Barrot H. Lambdin, Ph.D., Lynn D. Wenger, M.S.W., M.P.H., and 
Pete J. Davidson, Ph.D.    July 8, 2020

"Nearly 70,000 people in the United States die each year from a drug overdose.1 Opioid-involved overdose deaths may be preventable by the timely administration of naloxone. Eleven countries have responded to health concerns regarding people who use drugs by opening sanctioned safe consumption sites; however, no such sites exist yet in the United States. Safe consumption sites provide a space for people to bring preobtained drugs and use them with sterile supplies under clean conditions and with safe disposal of used drug equipment. These sites provide monitoring by staff equipped and trained in the use of naloxone to reverse overdose. Most sanctioned sites can also provide related services, including voluntary screening for infectious diseases, peer counseling, wound care, and referral to other social and medical services, such as substance use treatment. 
"In September 2014, in response to a local opioid overdose crisis, an organization in an undisclosed U.S. city opened an unsanctioned safe consumption site

"Although this evaluation was limited to one city and one site that is unsanctioned, and therefore the findings cannot be generalized, our results suggest that implementing sanctioned safe consumption sites in the United States could reduce mortality from opioid-involved overdose. Sanctioning sites could allow persons to link to other medical and social services, including treatment for substance use, and facilitate rigorous evaluation of their implementation and effect on reducing problems such as public injection of drugs and improperly discarded syringes."