This is Port Meadow which is the largest area of common land in Oxford
which is where we come from.
The management of the commons first arose to manage natural resources
like the grazing of common lands like these.
But I always talk about a different kind of global commons,
namely, the management of infectious disease.
So, infectious disease raises lots of interesting issue about common grounds
because each time one of us is infected and ill,
we’re also infectious and also pose a risk to those around us.
As I said, that raises many issues about the role of the individual
and the control of infection in the community.
And I would like to talk about just one of those
which is managing the emergence of drug resistance.
These discreetly lines represent the new middle age gene of H1N1 influenza.
It’s actually the old seasonal flu.
That’s the single difference which is pretty hard to spot between the two.
The top... sensed it. The bottom one is drug resistant.
That single point mutation when does our first line drug Tamiflu pretty much useless.
We learned from treating HIV that treating viruses like flu or HIV with single drugs
is a mistake because it drives drug resistance,
nor do we treat HIV with a single drug now
and regiments that contain up to four drugs a bit common.
It’s not just a problem for viruses.
So back in the 1940s Chloroquine was introduced to treat malaria
and by the 1950s Chloroquine resistance was common.
And for the past 70 years we’ve been in a pharmacological arms race
with malaria in which we introduced new drugs
but then drives the emersions of drug resistance.
At the moment we only have one good drug left and that’s the...
in based compounds but, sadly, just now, this year
malaria parasites were described in Western Cambodia
that are developing drug resistance to these drugs
and that’s despite pretty quite careful efforts to try and slow the spread of drug resistance
by only using these drugs in combination therapies.
So is it all always hopeless? I’d like to argue not.
When you use TB as a study to think about what can be done about this, now,
TB is an enormous global health problem.
Don’t get me wrong, but I think TB is solved,
but there are intense shared efforts to try and resist the spread of drug resistance for TB.
And the cornerstone of that is that every time...
in many countries every time a TB patient takes their TB drugs
somebody is there to watch them do it, a health care worker or a volunteer.
That’s called DOTS for directly observed treatment short course
and it’s the cornerstone of Stop TB.
Stop TB is a big global alliance of agencies
working to eliminate TB as a public health problem.
And if you look at the statement of principles and values of Stop TB,
what you see is that they match right top
with the properties that allow a bunch of users over resource...
to make an effective institution to regulate that resource.
So back to influenza, I already told you that just one point mutation
makes H1N1 flu resistance Tamiflu.
Now I can tell you now that this is a bust that makes mutations all the time.
In the all seasonal flu the drug resistant form is very fit.
That means it spreads between people, or of ferrets,
first actual animal model for flu, just as well as a drug sensitive form.
It graze perfectly well inside people.
And as to colds if we have problems,
because it means that the drug resistant form can spread very well
even if you don’t have it driven by an awful lot of treatment.
And that’s exactly what happened in Europe during the winter two years ago,
the winter 2007, 2008.
At the beginning of that winter flu season in Europe
most of the H1N1 flu was drug sensitive.
But as you can see, by the end of that season just a few months later,
the majority of H1N1 flu was drug resistant.
Now, let me tell you that in that winter
few of the one million prescriptions for Tamiflu were written in Europe.
The pandemic flu also has an H1 neuraminidase gene,
so what about swine flu?
Again, the last year the old season of flu was virtually all drug resistant,
but at that time and still now,
the vast majority of pandemic flu is still drug sensitive.
But this drug resistance is like a bad thing in Pandora’s Box.
Once it comes out, because there’s virtually no fitness caused the resistance mutation,
you can’t get rid of it again no matter how much you restrict flu,
has access to the drugs, or how they use them.
So the continuing existence that these drugs hosted viruses is a global commons.
And when we blindly treat, the drugs that treat these things
as though they have a consumer goods, these could suffer from a tragedy of the commons.
Now, we know from the management of more common resources,
the more common food resources
that if people can communicate freely about how to use the resources,
if there are ways to enforce what they agree,
and if everybody agrees that the long term exploitability of the resource
is very important to them, then it’s possible to make good rules that people will stick to
so as not to have a tragedy of the commons.
And I’d like to argue that we want to use those sorts of things we know about
managing resources more widely in the management of infectious disease.