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Should the sale of antibiotics be restricted?

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stellavision
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I'm trying to work this one out on my own and haven't figured out the answer yet, so I could use some help.

As those who read my healthcare blog, ReasonPharm, will know, I'm a staunch advocate of a free market in medicine -- including removing the prescription requirement from drugs, because the nanny state should not be able to tell me I *have* to see a doctor for medicines I am putting in my own body. No one will bear the risk but me, so why should the government be able to interfere?

The one area where I'm not sure if this applies is antibiotics. Under laissez-faire capitalism, the manufacturer has the right to sell whatever drugs he wishes at whatever price the market will bear, and the patient has the right to purchase whatever drugs he or she pleases. If a drug gets misused -- say, a man decides to take birth-control pills on a lark and he feels nauseous -- nobody's rights are violated just because the patient unwisely took a drug that was no use to him. But, with antibiotics and antivirals, this is not true. Bacteria and viruses quickly evolve defenses against drugs, more so the more often these drugs are used. More potent (and often more toxic) therapies then need to be used to kill these resistant bugs, and eventually you get "superbugs" that can't be stopped with pharmaceuticals. In this case, misuse of a drug *potentially* (though not always actually) causes harm to people other than those taking the drug, because a resistant strain could infect others.

This being the case, does the right to buy and sell win, or does the fact that one does not have the right to violate others' rights, even unintentionally (as with a sick person who may forcibly be quarantined to keep him from infecting others), win?

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On the other hand, the fact that the antibiotics producers are selling that many more antibiotics because of trivial applications means that they will make more profit, and therefore have more money available to invest in R&D so they can develop new antibiotics to fight the resistant strains. I mean, superbugs cannot be resistant to non-existing compounds, so as long as people keep inventing new drugs I don't really see the problem.

We also fight off infections with our immune system, and that is another thing that pathogenic organisms have been trying to circumvent since the beginning of time, so they can infect us. You could just as easily claim that people who are very resistant to pathogenic strains are ultimately causing those organisms to overcome their defenses in other ways (because otherwise the pathogenic organism would just die out, if it couldn't infect anyone any longer). And that may very well end up penalizing someone with a much weaker immune system, because if it can circumvent the strong one and cause some damage, it can probably trample all over those with weakened defenses.

I don't think there is a major conceptual difference between our own immune systems applying selective pressure to the evolution of pathogenic organisms, as compared to antibiotics doing the same thing. I don't think people taking antibiotics when they aren't needed is any worse than someone's natural defenses doing the same thing. And in the end, I do not think anyone should make the decision for another person whether they need the antibiotics badly enough to warrant their use. It should be up to that person to decide that, rather than another person who doesn't have the same intimate knowledge of the context available to him. Sure, it will get misused some times, but I think that is just something that's inherent in the system, and like I said above, when many more people buy these drugs the companies will have more money available to develop new variant antibiotics that *are* effective, and because we wouldn't have a FDA any longer that process would be ten times faster.

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I am a pharmacist too, and I agree that the sale of anti-biotics should be under some supervision. It's akin to chemical warfare of sorts if one were allow their sale to be fully de-regulated. I liken the comparison to objective gun control laws.-It's moral that man has the right to own a handgun, taser, rifle, or shotgun, but obviously it is not moral to allow him to possess nuclear weapons or weapons of large scale destruction. The former are weapons of self defense whereas the latter are weapons of total offense.

With antibiotics being fully de-regulated it would unleash a superbug nightmare that could be considered a biological attack against society.

Maarten, you are wrong on your assessment.

Edited by Erik Christensen
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I am a pharmacist too, and I agree that the sale of anti-biotics should be under some supervision. It's akin to chemical warfare of sorts if one were allow their sale to be fully de-regulated. I liken the comparison to objective gun control laws.-It's moral that man has the right to own a handgun, taser, rifle, or shotgun, but obviously it is not moral to allow him to possess nuclear weapons or weapons of large scale destruction. The former are weapons of self defense whereas the latter are weapons of total offense.

With antibiotics being fully de-regulated it would unleash a superbug nightmare that could be considered a biological attack against society.

Maarten, you are wrong on your assessment.

I don't see how antibiotics are in any way similar to nuclear weapons....

And thanks for explaining the reasons why I'm wrong. That was very productive... :rolleyes:

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Maarten, I wasn't trying to be offensive. I was drawing a comparison on the wide scale death that would ensue were the government allow a full deregulation of all anti-biotic medication. It is akin to a non-violent biological attack against the individuals in society. Just as the US government does not allow the sale of biological agents that terrorists want on the counter of your local Wal-Mart, so too must they protect the population at large against a threat even more nefarious, anti-biotic resistant super-bugs. If you're like me, when you get a tooth infection or an infection from a cut or what not, you probably don't want to die from something that trivial. The mortality that would ensue from drug resistant strains would be staggering. In fact, it's hard enough trying to keep a hold on it now. I think that you may be confusing viral infection with bacterial. They are very different.

You said "I don't think people taking antibiotics when they aren't needed is any worse than someone's natural defenses doing the same thing."

May I recommend taking a course on immunology and pharmacology?

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With antibiotics being fully de-regulated it would unleash a superbug nightmare that could be considered a biological attack against society.

Maarten, you are wrong on your assessment.

Argh! Don't fall for this hypothesis. The superbug, or supervirus, the unlivable polluted planet, and any other number of pandemic sorts of senarios should make one stop right there and question where they're going.

The nature of viruses and bacteria themselves will assure that no such senario ever exists. Here are a couple of points to consider.

a. "resistance" is not additive, and antibiotics use all sorts of offensive mechanisms to do their job. There is no superbug created over successive generations of antibiotics classes.

b. The use of antibiotics causes evolutionary pressure that creates resistance. When that evolutionary pressure is eliminated, then resistance to that antibiotic disappears as quickly if not more quickly than it was built up. What causes the elimination of that evolutionary pressure? Why simple, the lack of utility of a paticular class of antibiotics. If a particular class of AB's falls out of favor and is prescribed less, then the resistance to that class disappears. In fact one could easily envision a strategy of antibiotic rotation to keep such drug classes fresh.

c. as to the creation of a "threat" as a violation of rights, I particularly liken this to the argument for regulating the use of cars as a preventer to pollution. It is not the action of a single individual that creates pollution, but it is a diffuse source phenomena. As such, treat it as a fact of nature. Who you going to sue exactly? Viral and bacterial resistance have existed since time immemorial. It is their nature to create such evolutionary mechanisms to survive. This sort of "superbug" - "misuse by humans" idea is the same one put forward by environmentalists when they talk of invasive species of plants that are "brought" to new regions by man's actions, like zebra muscles in the great lakes. No it is not man's fault. That is something in nature called natural selection.

d. if resistance lifetime (i.e. the time it takes for parasite classes to build significant resistance) is shorter than the drug development cycle, then it is in the pharma companies interest to encourage the "proper" use of antibiotics. That is a plain free market mechanism right there. If it is longer than the development lifecycle, then who cares! (because of a, and :rolleyes:.

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May I recommend taking a course on immunology and pharmacology?

Uh, excuse me. What course in immunology and pharmacology posits a worldwide pandemic of the ture of nuclear war? May I suggest you not condescend quite so much?

The mortality that would ensue from drug resistant strains would be staggering.

The lack of mortality that today ensues from the use of antibiotics is already staggeringly good, but somehow you're positing that this trend will incredibly reverse itself so drastically at some point? Walk me through that Erik. Smells awfully fishy.

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Three points:

1. Let’s first of all consider Citizen A alone. If the likelihood of the drug’s effectiveness is great and the risk of its long-term harm to A low, there is no question of what A should do. He will choose to prolong his life by taking the drug. On the other hand, if the risk to him is substantial, A will shun the drug for another therapy.

2. Now let’s bring in other parties. What if the drug’s risk to A is very low, but poses some or even great risk to his fellow men? Does A have an obligation to forgo a life-saving treatment in order to minimize risk to others? The egoist must say “no.” Unless there is a danger to particular individuals whose well being is essential to A’s happiness, A must put his own life first.

3. In either case above, government intervention is questionable. In Case 1, Citizen A does not need a busybody government’s advice. In case 2, we must ask, where is the rights violation? My taking a drug may increase the chances of a bug developing a resistance. But in the same way, my putting up a fence may increase the chances of a burglar learning how to climb fences. Should we ban fences? It is far from certain that government is the best agency for limiting drugs with a potential to do harm. Bureaucrats typically place job-preservation over public interest. Why would they necessarily respond to science more readily than political pressure? Is banned marijuana really more harmful than legal alcohol? Moreover, even if officials are well-intentioned, there is no way to predict the long-term effects of keeping a particular product off the market. Do we really know that banning Medication X will save more lives than allowing its sale? More controversially, do we know that the lives saved by banning Medication X are worth more than those saved by its use? Would we sacrifice a scientific genius to save a hundred fruit-pickers?

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Uh, excuse me. What course in immunology and pharmacology posits a worldwide pandemic of the ture of nuclear war? May I suggest you not condescend quite so much?

Well, the spanish flu wiped out 50 million people in about 6 months.

b. The use of antibiotics causes evolutionary pressure that creates resistance. When that evolutionary pressure is eliminated, then resistance to that antibiotic disappears as quickly if not more quickly than it was built up. What causes the elimination of that evolutionary pressure? Why simple, the lack of utility of a paticular class of antibiotics. If a particular class of AB's falls out of favor and is prescribed less, then the resistance to that class disappears. In fact one could easily envision a strategy of antibiotic rotation to keep such drug classes fresh.

What it sounds like you are talking about here is essentially the 'domestication' of bacteria and virus, and while that would probably work very well, it is not at all what people are doing with antibiotics. This would require everyone to essentially use the same antibiotic until it is no longer very useful, then switch to another one, until that is no longer very useful. How would you plan on getting everyone to use the exact same antibiotic?

The problem with that is that all kinds of antiobiotics are always being used and many bacteria have been found to absorb free floating DNA from other bacteria which had been killed. Our purification systems are geared toward destroying living bacteria, not breaking up free floating bits of DNA. Farmers use broad scale antibiotics doses to bring calf to viability much quicker (for some unkown reason lots of antibiotics makes cows grow much faster) they doses are broad doses of many kinds of antibiotics. Those antiobiotics are then released back into the environment where bacteria are killed by them, but some survive. The free floating DNA of those survivors once they perish is readily incorporated into other strains. In other words, bacteria can become resistance to antibiotics it has never before actually encountered.

Conversely, as a patient I certainly wouldnt want to be admistered an antiobiotic which is dimishing in efficaciousness. Today many doctors prescribe two types of antiobiotics simaltaneously, in dangerous infections in the hospital, they may prescribe three or four. I don't think the answer is an easy one because of the large scale externalities that can come from abusing antiobiotics, I do liken this, like stellavision and Erik to something similiar to quarenteening people or limited the types of weapons people can get.

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A few points:

1) Drug-resistant bugs are real. Bacteria, although they reproduce asexually, do exchange genetic material with each other; sometimes between different species. There fore if one bacterium manages to develop resistance, it can potentially confer such abilities to other bacteria.

2) The problem is not limited to bacteria. Evolution is about adaptation to an environment. Think of taking medication as poisoning the environment viruses, bacteria and parasites live in, naturally they adapt sometimes. The malaria parasite mananged to adapt to quinine, the AIDS virus constantly adapts to drugs that try to defeat it.

3) The partial good news is that evolution is also about passing on genes. A bug that kills its host too quickly may not manage to survive outside the corpse. This means some bugs become less lethal with time. others jus kill mroe slowly, giving their host time to infect others.

4) While the government should not madate presciptions for drugs, pharmaceutical companies can do so. Many, if not all, would do so to protect themselves from potential liabilities. I'm thinking more on the lines of opiates, methamphetamines and such, but it could apply to antibiotics due to drug resistant strains.

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4) While the government should not madate presciptions for drugs, pharmaceutical companies can do so. Many, if not all, would do so to protect themselves from potential liabilities. I'm thinking more on the lines of opiates, methamphetamines and such, but it could apply to antibiotics due to drug resistant strains.

I agree with this. I don't see why this is should be a governmental matter. Pharmaceutical companies can set the rules for how their drugs are prescribed. Obviously, they have an interest in seeing that organisms do not become resistant to the antibiotics they manufacture. The longer their antibiotic remains effective, the more money they make. Let the pharmaceutical companies set the rules, not government.

I was drawing a comparison on the wide scale death that would ensue were the government allow a full deregulation of all anti-biotic medication. // The mortality that would ensue from drug resistant strains would be staggering.

In response to this, I have a question. Why haven't we seen this wide-scale death in Mexico or the many other countries where anyone can buy antibiotics right from the pharmacy without a prescription?

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Well, the spanish flu wiped out 50 million people in about 6 months.

Well considering penicillin was discovered in 1928 and this epidemic happened in 1918, it would be tough to claim this was a super bug created by antibiotic resistance. Plus flu is a virus, and antibiotics work on bacteria. The fact that such strains of viruses exist does not in any way imply that antibiotics or any other drug meant to combat them create them.

What it sounds like you are talking about here is essentially the 'domestication' of bacteria and virus, and while that would probably work very well, it is not at all what people are doing with antibiotics. This would require everyone to essentially use the same antibiotic until it is no longer very useful, then switch to another one, until that is no longer very useful. How would you plan on getting everyone to use the exact same antibiotic?

The problem with that is that all kinds of antiobiotics are always being used and many bacteria have been found to absorb free floating DNA from other bacteria which had been killed. Our purification systems are geared toward destroying living bacteria, not breaking up free floating bits of DNA. Farmers use broad scale antibiotics doses to bring calf to viability much quicker (for some unkown reason lots of antibiotics makes cows grow much faster) they doses are broad doses of many kinds of antibiotics. Those antiobiotics are then released back into the environment where bacteria are killed by them, but some survive. The free floating DNA of those survivors once they perish is readily incorporated into other strains. In other words, bacteria can become resistance to antibiotics it has never before actually encountered.

Conversely, as a patient I certainly wouldnt want to be admistered an antiobiotic which is dimishing in efficaciousness. Today many doctors prescribe two types of antiobiotics simaltaneously, in dangerous infections in the hospital, they may prescribe three or four. I don't think the answer is an easy one because of the large scale externalities that can come from abusing antiobiotics, I do liken this, like stellavision and Erik to something similiar to quarenteening people or limited the types of weapons people can get.

I'll answer you and Dkain in the same stroke here. It is genetic mixing that is also the cuprit in eliminating antibiotic resistance lacking the presence of a selective pressure for it. And hosts are individual cultures so there is not one aggregate culture that is slowly growing in resistance.

Also, remember that the only pressure is the mechanism of the antibiotic itself. The fact that bacteria are faced with this pressure does not in any way imply that they will evolve traits of virulence in humans. The bacteria that survive are the heartiest at resisting the mechanism of the antibiotic, not the more virulent, in general. Plus, extreme virulence is not a particularly good survival strategy (witness why no one worries much about Ebola, unless you're a sub-Saharan gorilla) because they burn their hosts out too quickly.

These are basic principles of natural selection. I think the conclusion that the overall level of resistance might rise by some amount is probably valid. however, extrpolating that to the example of a highly virulent (not antibiotic resistant) superbug is not where natural selection takes you.

Edited by KendallJ
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Also, remember that the only pressure is the mechanism of the antibiotic itself. The fact that bacteria are faced with this pressure does not in any way imply that they will evolve traits of virulence in humans.

True. Consider the symbiotic bacteria that infest you, and which you require in order to live. Many of them have become resistant as well.

But they in turn may exchange genetic material with, say, a pneumonia strain that may then acquire resistence. The problem, therefore, lies in bacteria which are already virulent becoming resistant.

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But they in turn may exchange genetic material with, say, a pneumonia strain that may then acquire resistence. The problem, therefore, lies in bacteria which are already virulent becoming resistant.

But that is an even less likely senario.

Resistance is not a general trait. The problem is therefore a bacteria that simultaneously becomes resistant to all mechanisms of currently known antibiotics. How is this to magically happen exactly? If it is first virulent, then by it's nature it will be present in small populations, and persist in short bursts. How does it build up this general resistance? It needs time, exposed to all classes of antibiotics simultaneously otherwise it's resitance will not build up.

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Drug resistant bacterial infections are not only growing in third world nations, but the technology to defeat these new strains is barely keeping up. Just Google it and you'll find tons of information on the problem. Part of the problem IS the easy accessability in 3rd world nations to anti-biotic drugs. What happens many times is that these bacteria become resistant from the wrong use of the medication etc., and these strains find their way into developed nations via the poorer countries. Just because an rx company can discover a new anti-biotic shouldn't mean it can be sold at their whim to whomever and whenever. Yes, they have a right to their work and a right to any monies profited thereby, but context is important here. It's like saying the individuals who built nuclear bombs have the right sell them and their technology to whoever desires them. That's insanity. Those are arguments that anarchists try to use to justify a free for all.

"A context-dropper forgets or evades any wider context. He stares at only one element, and he thinks, "I can change just this one point, and everything else will remain the same." In fact, everything is interconnected. That one element involves a whole context, and to assess a change in one element, you must see what it means in the whole context."

---Leonard Peikoff

Edited by Erik Christensen
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The mortality that would ensue from drug resistant strains would be staggering. In fact, it's hard enough trying to keep a hold on it now.

Hi Erik,

I didn't see a thing in your primer that supports this claim.

I did see a lot that discusses resistance of virulent strains of bacteria commonly found in [specific closed or close-proximity sorts of target locations such as] hospitals, etc.

Certainly staph and sepsis are significant concerns in such environments and antibiotic resistance would be a concern there, but this is not what I would call a "superbug" pandemic senario.

Following up on Galileo's question, a seemingly very easy place to look for even early empirical evidence of such "superbug" phenomena would be to look for pandemics in animal populations which are widely fed antibiotics on a prophylactic basis. These are usually close communities so it might be somewhat like the hospital case, but if you could show cross-farm epidemics with strains that are specifically antibiotic resistant to antibiotics commonly in use that wipe out whole animal populations in an entire region then you might have some evidence for such a hypothesis. I don't seem to recall any examples of these coming to mind though.

Just Google it and you'll find tons of information on the problem.

Why don't you bring us an example, if they are that easy to find. That way we can discuss the same one and check the context and magnitude of the problem. I wouldn't want to bring you one you'd only call a "strawman" later so why not bring us your best example.

It's like saying the individuals who built nuclear bombs have the right sell them and their technology to whoever desires them. That's insanity. Those are arguments that anarchists try to use to justify a free for all.

Its not insanity as you have yet to show us your "nuclear bomb" analogy is relevant. That antibiotic development is hard enough right now, and that we might just be keeping up is nothing I'd disupute. It is the senario that seems to loom "just around the corner" that a virulent AND resistant bacterial strain is going to come into being and kill off millions of people in one staggering event, that I find to be insanity.

Edited by KendallJ
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But that is an even less likely senario.

Cattle are fed antibiotics because they grow faster that way. Some drug resistant bugs come from that practice.

Resistance is not a general trait. The problem is therefore a bacteria that simultaneously becomes resistant to all mechanisms of currently known antibiotics.

Probably not. But not all antibiotics affect all bacteria equally. If some species that isn't affected by sulfa does not gain resistence to sulfa, well, what's changed?

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Its not insanity as you have yet to show us your "nuclear bomb" analogy is relevant. That antibiotic development is hard enough right now, and that we might just be keeping up is nothing I'd disupute. It is the senario that seems to loom "just around the corner" that a virulent AND resistant bacterial strain is going to come into being and kill off millions of people in one staggering event, that I find to be insanity.

Also, it is incredibly disadvantageous for a pathogenic organism to kill its host organisms *that* effectively. It's veritable suicide for them, kinda like trying to blow up the planet you're living on. Most current diseases that are very antibiotic resistant are not a problem for the general population; there's a reason they primarily occur in hospital environments, because they kill people whose immune systems are so weakened that they cannot fight off the infection themselves, and then if the antibiotics fail they're screwed.

You don't see MRSA wiping out whole cities mostly because for the general population it's not going to do anything to you. And yes, if we suddenly got a Yersinia pestis strain that was totally resistant to antibiotics we'd be in fairly big trouble. But again, it doesn't make any sort of evolutionary sense for a bacterium to be too effective at killing its host; the goal for them is to keep them alive fairly well so they can reproduce more. If the host dies before they can infect other people the bacteria just die along with the host when they run out of food. It wouldn't surprise me if there are many mechanisms in place so that pathogenic organisms don't become too successful.

Another thing is, if a pathogen kills off so many people, there's a good chance the rest of the population didn't die because they were resistant to it. It is *not* in a pathogen's best interests to select for very strong resistance in its target population, because then it'd just die out, having nothing to live off of. So I think the evolutionary pressure against such organisms becoming too successful is very strong, and that is probably one of the balancing factors that keeps such things from happening on a regular basis.

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But again, it doesn't make any sort of evolutionary sense for a bacterium to be too effective at killing its host;

It doesn't have to make evolutionary sense. It just has to happen.

It is *not* in a pathogen's best interests to select for very strong resistance in its target population, because then it'd just die out, having nothing to live off of.

Indeed it's not. I could make a good case to the effect that the most successful pathogen is the common cold virus, it's not even worth getting rid of. BUt a pathogen has no notion of what's in its best interest, or even that there's such a thing as best interest. It will blindly follow whatever its genes code for, regardless of whether it succeeds or not.

It is also well-known that many species have gone extinct becasue they made the wrong adaptations. That can happen with bacteria, too. It would be small consolation to know after it's done killing us, the resistant pathogen will die anyway.

And let's not forget some bugs can survive just fine, if in a dormant state, outside a host for years. How long can anthrax linger in the soil?

So I think the evolutionary pressure against such organisms becoming too successful is very strong, and that is probably one of the balancing factors that keeps such things from happening on a regular basis.

It may be. And judging from the lack of other rational species in our planet, and the lack of rationality even in those species closest to us, that a rational mind is an unlikely development with little or no evolutionary pressure behind it. Yet here we are.

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In response to this, I have a question. Why haven't we seen this wide-scale death in Mexico or the many other countries where anyone can buy antibiotics right from the pharmacy without a prescription?

Probably because most people are too poor to buy them in most of the countries in question.

I know from experience that in Spain and Mexico drugs are cheaper with a prescription than without. For some reason one gets a discount when a drug is dispensed with a prescription from a physician. This goes both for controlled substances that you have to ask the pharmacist for and off-the-shelf stuff like cold meds. It's some kind of price control afforded regardless of income. Why they'd charge someone buying without a doctor's note is puzzling. I'm not clear on the policy or economic purpose of that. Don't know if it's to discourage self-diagnosing or self-medicating.

If that's the case, then a poor person (which is most of the population in places like Mexico) can't self medicate because they couldn't afford it. On the other hand, they could go to the doctor at no cost to them, and then get the meds at a huge discount.

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Also, it is incredibly disadvantageous for a pathogenic organism to kill its host organisms *that* effectively. It's veritable suicide for them, kinda like trying to blow up the planet you're living on. Most current diseases that are very antibiotic resistant are not a problem for the general population; there's a reason they primarily occur in hospital environments, because they kill people whose immune systems are so weakened that they cannot fight off the infection themselves, and then if the antibiotics fail they're screwed.

This happens to some extent with the Ebola virus. It has not spread into something that is killing us all because it kills so quickly. That is why you see sporadic mass dieoffs dotted around from place to place where, say, a whole village is killed off but then it suddenly stops and all the surrounding villages aren't affected. That's because the virus has killed off its hosts so quickly, it limits its ability to propogate.

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Why they'd charge someone buying without a doctor's note is puzzling. I'm not clear on the policy or economic purpose of that. Don't know if it's to discourage self-diagnosing or self-medicating.

I live in Mexico and I can assure you that's not quite the case.

Many pharmacies give discounts to drugs purchased through insurance or corporate plans. To buy them those in the plan must present a card from their insurer or employer and a medical prescription (most plans don't cover self-medication). I've bought plenty of drugs, prescription and over the counter, and I've never had a discount merely for presenting a prescription.

If that's the case, then a poor person (which is most of the population in places like Mexico) can't self medicate because they couldn't afford it.

Medicines here are cheaper than in America (most of them at any rate), but still too expensive for a large portion of the population. There are alternatives, namely generic drugs and, cheapest of all, drug analogues. These are drugs similar to patented drugs but not quite the same. They're supposed to ahve the same effect, but that is disputed. Anyway, lots of people buy them.

As for self-medication, though most drugs require a prescription, this is enforced only in a few cases, mostly opiates, methamphetamines and the like. I suppose because of this more people self-medicate than would be the case elsewhere. One thing I cn tell you for certain is a lot of people pop antibiotics like pop-corn whenever they're afflicted by a cold or the flu.

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