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In wealthy health systems, when a biologic fails, patients
often have options: new lines of therapy, rapid drug
switching, advanced diagnostics, and specialist
consultations. Failure, while disruptive, is buffered by
access.

But in many parts of the world, failure is final.

In lower-income and under-resourced settings, a failed
biologic isn’t just a clinical setback—it’s a catastrophic
event. There may be no second-line therapy. No
opportunity to retry. No infrastructure to pivot.

This is the tolerization divide: a systemic inequity where
immunogenicity hits hardest in the very places that can
least absorb its consequences.

When Switching Isn’t an Option

The current biologic paradigm assumes failure is
manageable:

• That a patient can be monitored regularly for signs
of ADA formation.
• That SLOR can be caught early, and the therapy
escalated or changed.
• That cold-chain logistics, infusion centers, and
prescription formularies will absorb the churn.

But what happens in a clinic that:

• Can only afford a single biologic per condition?
• Can’t store or transport drugs that require
refrigeration?

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