Graphic: Freepik
I recently received the lab report of a culture and sensitivity test.
Basically, I had sent a sample of a patient’s phlegm to identify the presence of a bacteria, as well as the antibiotics that would work against it.
In this particular report, the word “RESISTANT” was repeated across all the antibiotics listed.
In other words, none of the antibiotics listed would work against the infection caused by the bacteria.
This happens more often than it should, and you would think that addressing multidrug resistant infections and developing new forms of antibiotics would be top of the list of medicine-makers across the globe.
Unfortunately, the truth is more complicated.
Need vs want
The pharmaceutical industry likes to present itself as a machine for meeting “unmet need”.
In practice, it is better described as a machine for meeting demand.
What people want, and can pay for (or can persuade an insurer or government to pay for), attracts capital, clinical trials and glossy advertising.
What people need however, too often waits, especially when there’s less money involved.
The last five years have been a case in point.
On one side, sit weight-loss medicines, led by GLP-1 drugs and their newer versions.
On the other, sits the under-rewarded world of antimicrobials, where a successful product is supposed to be used less, not more.
The money has voted.
Obesity’s big profits
The GLP-1 drug semaglutide was approved in 2021 and has become a commercial phenomenon.
Sales climbed from approximately US$200mil (RM811mil) in its first year to roughly US$8bil (RM32.4bil) in 2024, according to an S&P Global Market Intelligence analysis.
Further rapid growth is expected.
The market’s “want” dynamic is now so strong that the Danish pharmaceutical company and GLP-1 drug pioneer Novo Nor-disk itself describes the GLP-1 category as increasingly consumer-driven.
This month (January 2026), a daily oral version of semaglutide was launched in the United States, priced at US$149 (RM604) a month, explicitly to widen the funnel of self-paying users.
Where consumer pull is strong, marketing follows.
American prescription drugmakers spent almost US$3bil (RM12bil) on national TV advertising in the first half of 2025 (up 12.2% year-on-year), with much of the increase driven by diabetes and weight-loss brands.
Investors have been rewarded handsomely.
In November 2025, American company Eli Lilly became the first drugmaker to break the US$1 trillion (RM4.05 trillion) valuation mark, powered by demand for its tirzepatide franchises.
Reuters noted that Eli Lilly’s shares were up more than 35% in 2025 at the time, and that its obesity/diabetes products generated over US$10bil (RM41bil) in a single quarter (more than half of their total revenue).
Crucially, this boom has not merely enriched shareholders; it has also inflated corporate spending.
Unfortunately, spending has not been done evenly across humanity’s priorities.
Novo Nordisk’s annual report shows research and development (R&D) spending rising as a share of sales to 16.6% in 2024, alongside large capital returns with dividends for 2024 of DKK50.683bil (RM32.24bil) and share repurchases of DKK20.181bil (RM12.84bil).
Eli Lilly’s Securities and Exchange Commission (SEC) filings tell a similar story.
The company has R&D spending totalling US$10.99bil (RM44.56bil) in 2024, while marketing, selling and administrative expenses reached US$8.59bil (RM34.83bil).
The same filing notes that dividends of US$5.20 (RM21.09) per share were paid in 2024, and the firm also authorised a US$15bil (RM61bil) share repurchase programme in December 2024.
The point is that where revenues are durable and demand is elastic, capitalism can fund both laboratories and buybacks.
A commercial paradox
The story is very different with antibiotics, or more accurately, antimicrobials (to cover drugs that not only kill bacteria, but other microorganisms too, e.g. fungus).
Here the need is existential, but the market signal is weak.
The death toll is not to be ignored.
The World Health Organization (WHO) estimates bacterial antimicrobial resistance (AMR) was directly responsible for 1.27 million deaths in 2019, and was a contributing factor in 4.95 million deaths.
But the amount of effort placed into finding solutions is deplorable.
In June 2024, the WHO reported that the number of antibacterial agents in the clinical pipeline increased from 80 in 2021 to only 97 in 2023.
The problem is not only quantity, but quality.
Reviews in medical journals continue to note a scarcity of genuinely novel (new) drug classes, and a mismatch between candidates in development and the pathogens driving the gravest resistance threats.
This is not because scientists forgot how to do microbiology.
It is because a good antibiotic is a commercial paradox.
Antibiotic stewardship demands restraint.
As doctors, we try our best not to use new and/or stronger antibiotics unless we have to, as we would like to delay the inevitable arrival of resistance.
The result is a market in which clinical success can be punished by low sales.
Covid-19 briefly showed what happens when governments step in to fix a market.
Public support de-risked both R&D and manufacturing.
A BMJ analysis estimates that the US federal government invested at least US$2.3bil (RM9.3bil) in R&D for the mRNA Covid-19 vaccines after the pandemic began (through March 2022).
This included US$1.7bil (RM6.89bil) supporting Moderna’s trials through the Biomedical Advanced Research and Development Authority (Barda) and US$490mil (RM770mil) through National Institute of Health-funded trials.
Meanwhile the commercial spoils were vast: Pfizer reported 2022 revenue of US$37.806bil (RM153.3bil) for its mRNA Covid-19 vaccine and US$18.933bil (RM76.66bil) for its Covid-19 drug nirmatrelvir/ritonavir (and disclosed full-year 2022 revenues of US$100.3bil [RM406.72bil]).
The state created credible demand, industry delivered at speed, and unsurprisingly, shareholders did not complain.
AMR lacks that architecture.
The best proposals increasingly converge on a simple idea: de-link reward from volume.
Britain has already piloted a subscription-style model in which firms are paid a fixed annual fee based on a health-technology assessment of the drug’s value, not the number of doses sold.
(The National Institute for Health and Care Excellenct [NICE] and the National Health Service [NHS] England awarded the first such Netflix-like contracts in July 2022 for the antibiotics cefiderocol and ceftazidime-avibactam).
The US has debated a larger version (the Pasteur Act) to create subscription contracts for antimicrobials that are deemed critical.
Want vs need
The point of this story is not that weight-loss drugs are frivolous – obesity is a serious disease accounting for high rates of death and illness.
The point is that the industry’s centre of gravity will always tilt towards first/rich-world wants unless governments deliberately pay for rich-world insurance.
Antibiotics are insurance: you only appreciate them when they are missing.
A system that can mobilise billions for medicines that reshape bodies and balance sheets can also mobilise the comparatively modest sums needed to keep routine surgery, chemotherapy and neonatal care safe.
The question is whether policymakers will build the incentives before the cupboard is bare.
Dr Helmy Haja Mydin is a consultant respiratory physician and Social & Economic Research Initiative chairman. For further information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
