Bearing witness

n engl j med 381;6 nejm.org August 8, 2019 antibiotics and finding strategies for preventing or treating infections that don’t rely solely on antibiotics.1 Nonprofit organizations could participate in developing new vaccines to prevent infections, as well as immunotherapies, nutritional-deprivation strategies, inflammatory modulators, and other approaches to treat them.3 The greatest challenge associated with a nonprofit-driven model is identifying seed capital for establishing such organizations. In this regard, we believe that making a one-time investment of a billion dollars to create several new nonprofits that sustainably discover and develop new antibiotics might be a better longterm investment than perpetually offering multibillion-dollar prizes or other pull incentives for each new antibiotic. Shifting to a new model of drug development will naturally threaten players with vested interests in for-profit discovery of antibiotics. Traditionalists will probably argue that nonprofits cannot replace for-profit industry as a vehicle for innovation. But for-profit companies haven’t been able to reliably generate sufficient income from the sale of new antibiotics to satisfy shareholder demands for revenue growth, despite frequently focusing their efforts on antibiotics with larger perceived markets at the expense of addressing unmet needs. The economic outlook for development of antibiotics will worsen over time as new ones reach the clinic and contribute to an ever-more commoditized market. The increasingly loud drumbeat calling for additional subsidies for the pharmaceutical industry to develop new antibiotics conflicts with the realities of the daunting U.S. federal debt that has been driven up by high health care costs, the low esteem in which the public holds the pharmaceutical industry, and rising concerns about the costs of pharmaceuticals. Such dynamics will impede policies that include new pharmaceutical subsidies, irrespective of their potential effectiveness. An alternative model for sustaining discovery of antibiotics is overdue. We believe it is time to seriously consider the establishment of nonprofit organizations for developing these lifesaving drugs.