The news Monday from the Centers for Disease Control and Prevention (CDC) on the incidence of resistant infections is disturbing but not surprising. CDC estimates that over two million Americans every year are affected by drug-resistant infections and of those, 23,000 die annually. The report notes that these figures are conservative and are likely an underestimate of the burden of resistant infections. While these numbers reflect domestic rates, antibiotic resistance is a global issue as well.

To further compound the issue, today’s antibiotic pipeline is nearly dry and has been for some time, with only a handful of large pharmaceutical companies and smaller biotech firms still engaged in antibiotic development. The threat of a so-called ‘post-antibiotic era’ – a time when there are no longer any effective antibiotic treatments – could become a reality without a concerted and comprehensive effort to combat this global threat. The evolution of drug resistance is an inherent risk of antibiotic use. The CDC report cited the development of new antibiotics and diagnostic tools, as well as programs and policies to support appropriate use of antibiotics, as being among the core strategies to combat resistance.

Clinical effectiveness and the relatively low cost of antibiotics have had the unintended consequence of contributing to overuse, accelerating the development of antibiotic resistance to all major classes of antibiotics. While there are some diagnostic tools available to support targeted treatment, it is often more time- and cost-effective for a physician to prescribe a relatively inexpensive, broad-spectrum antibiotic than to conduct a diagnostic test (if one exists at all). Antibiotic overuse can also be driven by patients who see antibiotics as safe and often low-cost cure-alls. Recognizing that these past patterns of overuse are dangerous, the clinical community is working diligently to curb inappropriate use and promote public health through stewardship and education programs. However, given the weakness of the current antibiotic development environment, it may be too little-too late; rates of resistance continue to rise globally while the number of effective therapies to treat many pathogens is dwindling. According to the CDC, resistance can be ”slowed but not stopped” – there will always be a need for novel antibiotics that can combat the evolution of these pathogens.

The current system for manufacturer return on investment for antibiotics, which are typically reimbursed at very low levels, is oriented towards volume sales. As a result, stewardship and educational programs geared toward limiting use of novel antibiotics create an ‘antibiotic development paradox.’ How can we incentivize investment in developing new effective antibiotics and also have successful programs that limit the use of these antibiotics in an effort to prevent or delay the development of resistance? Unless this fundamental conflict in the current business model is addressed, pharmaceutical firms are unlikely to expand development efforts.

How do we turn the tide?

There are several proposals that address aspects of the antibiotic development paradox with the goal of reinvigorating the antibiotic drug development ecosystem in a way that maximizes our ability to stay ahead of resistance. While none of these proposals alone will solve this problem, each could support the long-term goal of reinvigorating antibiotic discovery, development, and treatment.

Creating incentives for drug development

Antibiotic drug development has been a losing prospect for drug developers and has driven many of them to exit the antibiotic innovation space in the last few decades in favor of other therapeutic areas that have much larger markets and are easier areas to study. In order to make antibiotic development more attractive, various mechanisms have been proposed to stimulate or better reward successful clinical development. Incentives that can lower the financial risks associated with development include grants, tax credits, public-private partnerships, and intellectual property protections. Post-approval, prizes, advanced market commitments, and value-based pricing could all potentially provide additional incentives to invest in this research. Some potential incentives were discussed at the Incentives for Change: Addressing the Challenges in Antibacterial Drug Development workshop convened by Brookings in February 2013.

Balancing benefit and risk for severely-ill patients

Other incentives are related to the drug approval process. Novel mechanisms for expedited development and approval can speed time to market while still meeting traditional evidentiary requirements for safety and efficacy. In the last several years, a number of proposals – including from the Infectious Diseases Society of America and the President’s Council of Advisors on Science and Technology – have sought to reduce development time and cost and increase regulatory clarity through a more targeted clinical trial process directed at the highest-risk patients. A narrower study population would allow the U.S. Food and Drug Administration to make a more targeted assessment of the product’s safety, efficacy, and benefit-risk profile that could accelerate innovation for patients with serious drug-resistant infections. The need to steward these antibiotics, which was noted as a core action in the CDC report, would be especially important to both prevent the growth of resistance and to reduce the risk of adverse effects in less seriously-ill populations. Additional information on the proposed limited-use pathway and appropriate use is available on the Brookings website.

De-link reimbursement from return on investment

In order to attract investment for new antibiotic research, we must develop a business model that can support ongoing and expanding development without compromising the effectiveness of new therapies. Recognizing the need to “de-link” return on investment from the volume of antibiotics sold, efforts to move away from the volume-based reimbursement system could become an attractive path forward. Promising models, which were discussed at the Brookings workshop in February, included several guaranteed payment schemes supported by public funding. Taken to an extreme, such a system could even allow new antibiotics to be reserved indefinitely until needed, removing the developer’s incentive to sell any drugs in the years following approval. While such a program would likely be expensive (with sufficient returns estimated on the order of $1.75-2.5 billion over five years), government intervention is needed to fix this public health crisis and dangerous market failure. Its societal value in curtailing resistance and providing critical drugs would outweigh the cost to taxpayers.

The antibiotic development paradox will require a multi-pronged strategy that includes incentives to support front-end drug discovery and development, and new reimbursement policies that de-link unit volume sales from return on investment. However, this is by no means a quick fix. Even if this approach is successful, it will take decades for manufacturers to rebuild lost antibiotic development infrastructure and expertise, and to successfully develop and market new treatments. For the few drugs currently in development, even with expedited development and review pathways, they are still years from reaching the market.

Editors' Note: It has perhaps never been more important to question the prevailing wisdom on the 2011 United States-led intervention in Libya, writes Shadi Hamid. Even with the benefits of hindsight, he argues, many of the criticisms of the intervention fall short. This post originally appeared on Vox.

Libya and the 2011 NATO intervention there have become synonymous with failure, disaster, and the Middle East being a "shit show" (to use President Obama’s colorful descriptor). It has perhaps never been more important to question this prevailing wisdom, because how we interpret Libya affects how we interpret Syria and, importantly, how we assess Obama’s foreign policy legacy.

Of course, Libya, as anyone can see, is a mess, and Americans are reasonably asking if the intervention was a mistake. But just because it’s reasonable doesn’t make it right.

Most criticisms of the intervention, even with the benefit of hindsight, fall short. It is certainly true that the intervention didn’t produce something resembling a stable democracy. This, however, was never the goal. The goal was to protect civilians and prevent a massacre.

Critics erroneously compare Libya today to any number of false ideals, but this is not the correct way to evaluate the success or failure of the intervention. To do that, we should compare Libya today to what Libya would have looked like if we hadn’t intervened. By that standard, the Libya intervention was successful: The country is better off today than it would have been had the international community allowed dictator Muammar Qaddafi to continue his rampage across the country.

Critics further assert that the intervention caused, created, or somehow led to civil war. In fact, the civil war had already started before the intervention began. As for today’s chaos, violence, and general instability, these are more plausibly tied not to the original intervention but to the international community’s failures after intervention.

The very fact that the Libya intervention and its legacy have been either distorted or misunderstood is itself evidence of a warped foreign policy discourse in the U.S., where anything short of success—in this case, Libya quickly becoming a stable, relatively democratic country—is viewed as a failure.

NATO intervened to protect civilians, not to set up a democracy

As stated in the U.N. Security Council resolution authorizing force in Libya, the goal of intervention was "to protect civilians and civilian populated areas under threat of attack." And this is what was achieved.

In February 2011, anti-Qaddafi demonstrations spread across the country. The regime responded to the nascent protest movement with lethal force, killing more than 100 people in the first few days, effectively sparking an armed rebellion. The rebels quickly lost momentum, however.

I still remember how I felt in those last days and hours as Qaddafi’s forces marched toward Benghazi. In a quite literal sense, every moment mattered, and the longer we waited, the greater the cost.

It was frightening to watch. I didn’t want to live in an America where we would stand by silently as a brutal dictator—using that distinct language of genocidaires—announced rather clearly his intentions to kill. In one speech, Qaddafi called protesters "cockroaches" and vowed to cleanse Libya "inch by inch, house by house, home by home, alleyway by alleyway."

Already, on the eve of intervention, the death toll was estimated at somewhere between 1,000 and 2,000. (This was when the international community’s tolerance for Arab Spring–related mass killings was still fairly low.)

As Obama’s advisers saw it, there were two options for military action: a no-fly zone (which, on its own, wouldn’t do much to stop Qaddafi’s tanks) or a broader resolution that would allow the U.S. and its allies to take further measures, including establishing what amounted to a floating no-drive zone around rebel forces. The president went with the latter option.

The NATO operation lasted about seven months, with an estimated death toll of around 8,000, apparently most of them combatants on both sides (although there is some lack of clarity on this, since the Libyan government doesn’t clearly define "revolutionaries" or "rebel supporters"). A Human Rights Watch investigation found that at least 72 civilians were killed as a result of the NATO air campaign, definitively contradicting speculative claims of mass casualties from the Qaddafi regime.

Claims of "mission creep" have become commonplace, most forcefully articulated by the Micah Zenko of the Council on Foreign Relations. Zenko may be right, but he asserts rather than explains why mission creep is always a bad thing. It may be that in some circumstances, the scope of a mission should be defined more broadly, rather than narrowly.

If anything, it was the Obama administration’s insistence of minimizing the mission—including the absurd claim that it would take "days, not weeks"—that was the problem from the very start. Zenko and others never make clear how civilians could have been protected as long as Qaddafi was waging war on them.

What Libya would look like today if NATO hadn’t intervened

It’s helpful to engage in a bit of counterfactual history here. As Niall Ferguson notes in his book Virtual Alternatives, "To understand how it actually was, we therefore need to understand how it actually wasn’t."

Applied to the Libyan context, this means that we’re not comparing Libya, during or after the intervention, with some imagined ideal of stable, functioning democracy. Rather, we would compare it with what we judge, to the best of our ability, the most likely alternative outcome would have been had the U.S. not intervened.

Here’s what we know: By March 19, 2011, when the NATO operation began, the death toll in Libya had risen rapidly to more than 1,000 in a relatively short amount of time, confirming Qaddafi’s longstanding reputation as someone who was willing to kill his countrymen (as well as others) in large numbers if that’s what his survival required.

There was no end in sight. After early rebel gains, Qaddafi had seized the advantage. Still, he was not in a position to deal a decisive blow to the opposition. (Nowhere in the Arab Spring era has one side in a military conflict been able to claim a clear victory, even with massive advantages in manpower, equipment, and regional backing.)

Any Libyan who had opted to take up arms was liable to be captured, arrested, or killed if Qaddafi "won," so the incentives to accept defeat were nonexistent, to say nothing of the understandable desire to not live under the rule of a brutal and maniacal strongman.

The most likely outcome, then, was a Syria-like situation of indefinite, intensifying violence. Even President Obama, who today seems unsure about the decision to intervene, acknowledged in an August 2014 interview with Thomas Friedman that "had we not intervened, it’s likely that Libya would be Syria...And so there would be more death, more disruption, more destruction."

What caused the current Libyan civil war?

Critics charge that the NATO intervention was responsible for or somehow caused Libya’s current state of chaos and instability. For instance, after leaving the Obama administration, Philip Gordon, the most senior U.S. official on the Middle East in 2013-'15, wrote: "In Iraq, the U.S. intervened and occupied, and the result was a costly disaster. In Libya, the U.S. intervened and did not occupy, and the result was a costly disaster. In Syria, the U.S. neither intervened nor occupied, and the result is a costly disaster."

The problem here is that U.S. intervention did not, in fact, result in a costly disaster, unless we are using the word "result" to simply connote that one thing happened after a previous thing. The NATO operation ended in October 2011. The current civil war in Libya began in May 2014—a full two and a half years later. The intervention and today’s violence are of course related, but this does not necessarily mean there is a causal relationship.

To argue that the current conflict in Libya is a result of the intervention, one would basically need to assume that the outbreak of civil war was inevitable, irrespective of anything that happened in the intervening 30 months.

This makes it all the more important to distinguish between the intervention itself and the international community’s subsequent failure—a failure that nearly all the relevant actors acknowledge—to plan and act for the day after and help Libyans rebuild their shattered country.

Such measures include sending training missions to help the Libyan army restructure itself (only in late 2013 did NATO provide a small team of advisers) or even sending multinational peacekeeping forces; expanding the United Nations Support Mission in Libya’s (UNSMIL) limited advisory role; and pressuring the Libyan government to consider alternatives to a dangerous and destabilizing political isolation law.

While perhaps less sexy, the U.S. and its allies could have also weighed in on institutional design and pushed back against Libya’s adoption, backed by UNSMIL, of one of world’s most counterproductive electoral systems—single non-transferable vote—along with an institutional bias favoring independents. This combination exacerbated tribal and regional divisions while making power sharing even more difficult.

Finally, the U.S. could have restrained its allies, particularly the Gulf States and Egypt, from excessive meddling in the lead-up to and early days of the 2014 civil war.

Yet Libya quickly tumbled off the American agenda. That’s not surprising, given that the Obama administration has always been suspicious of not just military entanglements but any kind of prolonged involvement—diplomatic, financial, or otherwise—in Middle East trouble spots. Libya "was farmed out to the working level," according to Dennis Ross, who served as a special assistant to President Obama until November 2011.

There was also an assumption that the Europeans would do more. This was more than just a hope; it was an organizing principle of Obama administration engagement abroad. Analysts Nina Hachigian and David Shorr have called it the "Responsibility Doctrine": a strategy of "prodding other influential nations…to help shoulder the burdens of fostering a stable, peaceful world order."

This may be the way the world should operate, but as a set of driving assumptions, this part of the Obama doctrine has proven to be wrong at best, and rather dangerous at worst.

We may not like it—and Obama certainly doesn’t—but even when the U.S. itself is not particularly involved in a given conflict, at the very least it is expected to set the agenda, convene partners, and drive international attention toward an issue that would otherwise be neglected in the morass of Middle East conflicts. The U.S., when it came to Libya, did not meet this minimal standard.

Even President Obama himself would eventually acknowledge the failure to stay engaged. As he put it to Friedman: "I think we [and] our European partners underestimated the need to come in full force if you’re going to do this."

Yet it is worth emphasizing that even with a civil war, ISIS’s capture of territory, and as many as three competing "governments," the destruction in Libya still does not come close to the level of death and destruction witnessed in Syria in the absence of intervention.

In other words, even this "worst-case scenario" falls well short of actual worst-case scenarios. According to the Libya Body Count, around 4,500 people have so far been killed over the course of 22 months of civil war.

In Syria, the death toll is about 100 times that, with more than 400,000 killed, according to the Syrian Center for Policy Research.

We’re all consequentialists now

For the reasons outlined above, Libya’s descent into civil conflict—and the resulting power vacuum, which extremist groups like ISIS eagerly filled—wasn’t inevitable. But let’s hypothesize for a moment that it was. Would that undermine support for the original intervention?

The Iraq War, to cite the most obvious example, wasn’t wrong because it led to chaos, instability, and civil war in the country. It was wrong because the decision to intervene in the first place was not justified, being based as it was on faulty premises regarding weapons of mass destruction.

If Iraq had quickly turned out "well" and become a relatively stable, flawed, yet functioning democracy, would that have retroactively justified an unjustified war? Presumably not, even though we would all be happy that Iraq was on a promising path.

The near reverse holds true for Libya. The justness of military intervention in March 2011 cannot be undone or negated retroactively. This is not the way choice or morality operates (imagine applying this standard to your personal life). This may suggest a broader philosophical divergence: Obama, according to one of his aides, is a "consequentialist."

I suspect that this, perhaps more than narrower questions of military intervention, drives at least some of the revisionism over Libya’s legacy. If we were consequentialists, it would be nearly impossible to act anywhere without some sort of preordained guarantee that a conflict area—which likely hadn’t been "stable" for years or decades—could all of a sudden stabilize.

Was the rightness of stopping the Rwandan genocide dependent on whether Rwanda could realistically become a stable democracy after the genocide was stopped? And how could policymakers make that determination, when the stabilization of any post-conflict situation is dependent, in part, not just on factual assessments but on always uncertain questions of the international community’s political will—something that is up to politicians—in committing the necessary time, attention, and resources to helping shattered countries rebuild themselves?

The idea that Libya, because it had oil and a relatively small population, would have been a relatively easy case was an odd one. Qaddafi had made sure, well in advance, that a Libya without him would be woefully unprepared to reconstruct itself.

For more than four decades, he did everything in his power to preempt any civil society organizations or real, autonomous institutions from emerging. Paranoid about competing centers of influence, Qaddafi reduced the Libyan army to a personal fiefdom. Unlike other Arab autocracies, the state and the leader were inseparable.

To think that Libya wouldn’t have encountered at least some major instability over the course of transition from one-person rule to an uncertain "something else" is to have a view of political development completely detached from both history and reality.

A distorted foreign policy discourse

The way we remember Libya suggests that the way we talk about America’s role in the world has changed, and not for the better. Americans are probably more likely to consider the Libya intervention a failure because the U.S. was at the forefront of the NATO operation. So any subsequent descent into conflict, presumably, says something about our failure, which is something we’d rather not think about.

Outside of the foreign policy community, politicians are usually criticized for what they do abroad, rather than what they don’t do. As former Secretary of Defense Robert Gates put it, "[Qaddafi] was not a threat to us anywhere. He was a threat to his own people, and that was about it." If the U.S had decided against intervention, Libya would have likely reverted to some noxious combination of dictatorship and insurgency. But we could have shirked responsibility (a sort of inverse "pottery barn" principle—if you didn’t break it, you don’t have to fix it). We could have claimed to have "done no harm," even though harm, of course, would have been done.

There was a time when the United States seemed to have a perpetual bias toward action. The instinct of leaders, more often than not, was to act militarily even in relatively small conflicts that were remote from American national security interests. Our country’s tragic experience in Iraq changed that. Inaction came to be seen as a virtue. And, to be sure, inaction is sometimes virtuous. Libya, though, was not one of those times.

Professor Riek Machar, former vice president of South Sudan and now leader of the rebel group that is fighting the government of South Sudan for control of the apparatus of the government, has publicly threatened to capture and take control of both the capital city of Juba and the oil-producing regions of the country. Branding South Sudan’s president, Salva Kiir, a “dictator” and arguing that he does not recognize the need to share power, Professor Machar stated that the present conflict, which has lasted for more than five months and resulted in the killing of many people and the destruction of a significant amount of property, will not end until Kiir is chased out of power.

Violent mobilization by groups loyal to Machar against the government in Juba began in December 2013. It was only after bloody confrontations between the two parties that targeted civilians based on their ethnicity had resulted in the deaths of many people (creating a major humanitarian crisis) that a cease-fire agreement was signed in Addis Ababa on January 23, 2014, with the hope of bringing to an end the brutal fighting. The cease-fire, however, was seen only as the first step towards negotiations that were supposed to help the country exit the violent conflict and secure institutional arrangements capable of guaranteeing peaceful coexistence.

If Machar and his supporters have the wherewithal to carry out the threats and successfully do so, there is no guarantee that peace would be brought to the country. For one thing, any violent overthrow of the government would only engender more violence as supporters of Kiir and his benefactors are likely to regroup and attempt to recapture their lost political positions. What South Sudan badly needs is an institutionalization of democracy and not a government led by political opportunists. In fact, an effective strategy to exit from this incessant violence must be centered around the election of an inclusive interim government—minus both Kiir and Machar—that would engage all of the country’s relevant stakeholders in negotiations to create a governing process that adequately constrains the state, establishes mechanisms for the peaceful resolution of conflict, enhances peaceful coexistence, and provides an enabling environment for the rapid creation of the wealth needed to deal with poverty and deprivation.

On March 9, 2012, less than a year after South Sudan gained independence, then-Vice President Machar met with several Brookings scholars, including myself, in New York City. The meeting was part of the new country’s efforts to seek assistance from its international partners to address complex and longstanding development challenges, including critical issues such as the effective management of the country’s natural resource endowments, gender equity, the building of government capacity to maintain law and order, the provision of other critical public goods and services, and poverty alleviation. Among participants in this critical consultation were Mwangi S. Kimenyi, senior fellow and director of the Africa Growth Initiative (AGI) at the Brookings Institution; Witney Schneidman, AGI nonresident fellow and former deputy assistant secretary of state for African Affairs; and me. The vice president, who appeared extremely energetic and optimistic about prospects for sustainable development in the new country, requested an analysis of the commitments and achievements that the government of South Sudan had made since independence and suggestions for a way forward. The scholars, working in close collaboration with their colleagues at Brookings, produced a policy report requested by the vice president. The report entitled, South Sudan: One Year After Independence—Opportunities and Obstacles for Africa’s Newest Country, was presented at a well-attended public event on July 28, 2012. Panelists included Peter Ajak, director of the Center for Strategic Analyses and Research in Juba; Ambassador Princeton Lyman, U.S. special envoy for South Sudan and Sudan; Nada Mustafa Ali scholar at the New School for Social Research; Mwangi S. Kimenyi and me.

The report provided a comprehensive review of the policy issues requested by the vice president—the provision of basic services; future engagement between South Sudan and the Republic of Sudan; efficient and equitable management of natural resources; ethnic diversity and peaceful coexistence; federalism; eradication of corruption; and the benefits of regional integration. Most important is the fact that the report placed emphasis on the need for the government of South Sudan to totally reconstruct the state inherited from the Khartoum government through democratic constitution making and produce a governing process that (i) guarantees the protection of human and fundamental rights, including those of vulnerable groups (e.g., women, minority ethnic groups); (ii) adequately constrains the government (so that impunity, corruption and rent seeking are minimized); (iii) enhances entrepreneurial activities and provides the wherewithal for wealth creation and economic growth; and (iv) establishes mechanisms for the peaceful resolution of conflict and creates an environment within which all of the country’s diverse population groups can coexist peacefully.

Unfortunately, when the report was completed, members of the ruling Sudan People’s Liberation Movement were already embroiled in a brutal power struggle that eventually led to President Kiir sacking his entire cabinet, including the vice president. The collapse of the government raised the prospects of violent and destructive mobilization by groups that felt the president’s actions were marginalizing them both economically and politically. The ensuing chaos created an environment that was hardly conducive to the implementation of policies such as those presented in the Brookings report.

The government of Sudan has failed to engage in the type of robust institutional reforms that would have effectively prevented President Kiir and his government from engaging in the various opportunistic policies that have been partly responsible for the violence that now pervades the country. South Sudan’s diverse ethnic groups put forth a united front in their war against Khartoum for self-determination. Following independence, the new government engaged in state formation processes that did not provide mechanisms for all individuals and groups to compete fairly for positions in the political and economic systems. Instead, the government’s approach to state formation politicized ethnic cleavages and made the ethnic group the basis and foundation for political, and to a certain extent, economic participation. This approach has created a "sure recipe for breeding ethnic antagonism," and has led to the crisis that currently consumes the country.

While the most important policy imperative in South Sudan today is the need to make certain that the cease-fire continues to hold, long-term prospects for peaceful coexistence and development call for comprehensive institutional reforms to provide the country with a governing process that guarantees the rule of law. Hence, both the opposition and the government—the two sides in the present conflict—should take advantage of the cease-fire and start putting together the framework that will eventually be used to put the state back together. A new interim government, without the participation of the two protagonists—Kiir and Machar—should be granted the power to bring together all of the country’s relevant stakeholders to reconstitute and reconstruct the state, including negotiating a permanent constitution.