Resistance to antibiotics is already killing millions. Professor Dame Sally Davies, UK Special Envoy on Antimicrobial Resistance, spoke to AIQ on the latest developments to counter antimicrobial resistance Antimicrobial Resistance (AMR) in the UK and globally.

Read this article to understand:

  • The latest global developments in the fight against antimicrobial resistance
  • What is needed now from the G7, international organisations and the pharma industry
  • Why this issue matters for investors

Professor Dame Sally Davies is UK Special Envoy on Antimicrobial Resistance (AMR), prior to which she was Chief Medical Officer (CMO) for England and Chief Medical Adviser to the UK government, from March 2011 to September 2019. Dame Sally advocates globally on AMR and, as part of Aviva Investors’ efforts to mitigate AMR risk, we have collaborated with her on several occasions.

We spoke to Dame Sally about progress to date, the conversations happening among world leaders, and what more is needed to develop sustainable antibiotic management.

In the last five years, what development in AMR has helped the most? 

Globally, we have made some progress since 2016 and the UN declaration on AMR, but it remains incremental.1 We started with the UN Interagency Coordination Group that reported in 2019, and we now have the Global Leaders Group on Antimicrobial Resistance (GLG), which was agreed in 2020 and started work in 2021.2,3 We have also seen focus on AMR from both the G7 and G20, and that begins to move everything forward.

COVID-19 played a role too because it woke everyone up to the fact infections can maim and kill, and damage economics, whether personal, family, community or societal.

Looking at the private sector, I am thrilled at the UK’s pilot study – for subscription-based payments by the NHS of new antibiotics – with the Shionogi and Pfizer drugs coming through, and at a valuation that seems fair for both society and the private sector.4 The UK’s subscription payments could start this summer.

That bodes well – and if we can get the US to pass the PASTEUR Act, it will be a global game changer. Given the size of the US market, it would be the biggest signal to the world, and we hope others would join in.5 Canada is also looking at the UK’s pilot for paying by subscription, so it is interesting we are beginning to work with other countries on AMR.

In the UK, the important part is to get that initiative going, and show that it works to build the range of drugs we can use on a subscription basis. We can then use stewardship to look after them, and we know it's good value for our health system to do it that way.

We have seen some great moves around investment and ownership

We have also seen some great moves around investment and ownership. I am thrilled about the work that has come together under the Investor Action on AMR led by the Access to Medicines Initiative, the FAIRR Initiative, the UN Principles for Responsible Investment and the Department of Health and Social Care in the UK.6 Aviva Investors was in on this from the beginning, helping work through what needed doing and how to do it, and has helped drive it.

The Investor Action on AMR now has 16 investors with combined assets of US$11 trillion using AMR in their ESG standards. Meanwhile, we have started discussions with large asset owners, and they are beginning to consider how they can help too. We are starting to see a snowball effect.

Industry also has a huge role to play. It is represented on the GLG and is leading the way through investor and asset-owner ESG action. Only by all working together we can make this work because it is terribly complex.

What role can other initiatives play, from liquid waste treatment at production sites to reduced antibiotic use in farming?

We need appropriate and sustainable antibiotic use and there is no doubt some countries use too much in humans and animals, while other countries use very little. We need to take that on and work with people to benchmark and regulate usage.

We must get at this overuse, but also underuse around the world, which is the access story. Maybe we need a metric to look at antibiotic use in different animals, including humans, to limit overuse and promote greater access where it is needed.

Some factories are better than others but industry needs to clean up its act

I am worried about manufacturing. Clean manufacturing can be done. In many factories (particularly of generics but not exclusively), their waste – as it comes out of the factory, and downstream if it goes into the water system – contains very high levels of active pharmaceutical ingredients (API) or antibiotics themselves. That is worrying. I talk about a Rachel Carson Silent Spring type of situation where we are building toxicity with the drugs in our environment. Some get broken down quite quickly, but others last for ages, and once they are in the environment, they can drive the development of resistance as well as toxicity. Of course, some factories are better than others, but industry needs to clean up its act, and we need to agree environmental standards.

What do the G7 finance ministers need to agree in June if we are to see real progress? 

We were delighted when finance ministers under the UK G7 Presidency picked up AMR. It showed they had learnt some lessons from COVID: that prevention is better and cheaper than a cure; that we need innovative pull mechanisms, incentives to build a strong pipeline of new drugs; and why we have market failure. They all agreed to conduct pilots of new ways to fund the pipeline and, while countries have different health systems and funding models thereby requiring them to run their pilots in different ways, we did agree on common principles to value the new drugs.

We need to build on that. It will be a multi-year effort, so it's not just the German G7 Presidency, but the Japanese and succeeding presidencies too, and we need firm timelines and milestones to hold each other to account. I am delighted that under Germany’s G7 Presidency this year, finance ministers requested a progress report in 2023.7

This effort needs to be funded because it is about trying innovative ways of paying for the health system at large

We need finance ministers to lead this because, in the end, if drug resistance gets out of hand, they will be the ones having to bail out their economies, as they did with COVID. And this effort needs to be funded because it is about trying innovative ways of paying for the health system at large.

When we had the G7 meeting in December 2021, we also involved the chief executives of all the major pharma companies and asked them what they were doing to make investments in AMR. They have set up the AMR Action Fund, which has announced its first two investments, which we are pleased about. We need this to just be the start, until we have stimulated and sustainable antibiotic markets. And, considering how important they are to our economies, it would be good if industry and the G7 continued to work closely together with open dialogue and partnership.

What is currently on the agendas of the GLG and the World Bank on AMR?

The GLG is chaired by two prime ministers, Mia Mottley of Barbados and Sheik Hasina of Bangladesh, and has ministers, senior experts and appropriate industry representation. Our role is to advocate for action on AMR.

We have reframed some of the issues, from talking about appropriate use to sustainable use of antibiotics and anti-infectives, and we are trying to ensure the world understands AMR needs a ‘One Health’ approach. It is a global problem, which means we need effective and coordinated action as well as multi-sectoral infrastructure and governance. That’s quite difficult.

We have been working on the pandemic treaty or legal instrument that World Health Organization member states are currently negotiating. As we argue, AMR is a pandemic, but a silent and insidious one. The GLG believes any pandemic instrument needs to integrate AMR alongside its primary focus on pandemics, especially as it would only need small tweaks to address different sources of pandemics, whether zoonotic or AMR.

One Health surveillance must be at the heart of any treaty or instrument

One Health surveillance must be at the heart of any treaty or instrument to enable rapid, transparent, and responsive detection of new viral or bacterial threats. It doesn't matter where the pandemic source is. Strong systems can deliver the surveillance on AMR and pivot for pandemic preparedness if needed. We have seen that happen, with good AMR genomics pivoting to COVID, for example. We think the pandemic treaty can create One Health mechanisms that allow member states to address AMR through subsequent actions and agreements.

We probably need a codex-type mechanism [a mandatory system to monitor the health of AMR mitigation] and a COP-type mechanism where countries come together on a regular basis to declare their commitments and ask for help where needed, because AMR is part of health security.8

We know it matters to finance ministries and development banks. The World Bank is now including AMR in its global investment framework so it can give grants and loans to support countries in delivering better surveillance and infection prevention, and control on the issues that matter to mitigate AMR.

What conversations do you expect to be having on AMR in one and five years’ time?

When I joined the conversation on AMR ten years ago, the discussion was, “Does it really matter? Is it significant?” I think we have persuaded people it is. The Global Burden of Disease study, published in February in The Lancet, showed just under 1.3 million deaths directly caused by AMR and up to five million deaths associated with AMR in 2019. That is a real call to action because it shows that, every year, there are more deaths from AMR than from HIV, malaria or tuberculosis.9

With COVID, we are now discussing how AMR is part of health security. But we need effective anti-infectives and antibiotics to treat sick animals and effective antifungals to treat plants, so food security is also an issue, along with environmental security, as we discussed earlier.

Animals excrete up to 90 per cent of the antibiotics and other anti-infectives they receive, raising the issue of how we clean that up, particularly with runoff from hospitals and high-intensity farming.10

In addition, if we don't have a secure food system, it isn’t sustainable, and that will feed back. But we also need sustainable pipelines, manufacturing, supply chains, and intensive farming. We can't get rid of intensive farming, but we can do it better, without growth promotion and prophylaxis. The conversation has to move from security to security and sustainability.

Where will that take us? I think it will take us to discussions on developing metrics for AMR and incorporating artificial intelligence so we can manage AMR risks better.

In five years’ time, the debate should have moved on to how we manage AMR better, with an acceptance of the importance of security and sustainability. A UN high-level meeting on AMR is also planned in 2024, and I hope we can say it was a pivotal moment that galvanised action from all parts of society across the globe including, importantly, the private sector.

What do you see as the private sector’s role in mitigating AMR?

We need all sectors to work together, and the private sector is terrifically important. We won’t solve this without better prevention of infections – better hygiene and infection prevention and control; vaccines for humans, animals, fish farming and maybe even plants; and better therapeutics.

We need a full pipeline and that means pharmaceutical companies have to recognise they are not going to make huge profits as they do, say, from cancer drugs, but they are doing their bit for humanity and protecting their other product lines.

We need more rapid, accurate, and affordable diagnostics

We also need more rapid, accurate, and affordable diagnostics. One of the big learnings from COVID was we can develop rapid self-administered diagnostics. We need to use this to move other diagnostics forward so we can use antibiotics appropriately and more effectively.

To help improve the pipeline, the AMR Action Fund was set up and funded by industry and has announced its first investments. It is seeking to bring two to four new antibiotics to market by 2030. G7 efforts to put in place incentives are part of this and I hope that's just the beginning.

But we also need academia to look for mechanisms of action and targets, SMEs to develop new therapeutics, vaccines and diagnostics, and the big companies to bring them to market.

But I want everyone to think about AMR. Consumers, supermarkets and fast-food chains have a huge impact on how things are done. We need them to align with global best practice on AMR by buying appropriately and, for companies, putting it into their ESG standards. That is why I'm excited about the Investor Action on AMR.11

What are some bad recommendations you hear in AMR conversations? And are there any aspects of AMR you say no to?

Everyone is always looking for the silver bullet, but there isn't one. This is complex and no one player can solve it on their own, so you have to ignore anyone who says they have the solution.

Siloed thinking doesn't work, and apportioning blame undermines action

Anyone who thinks it's the fault of the animal and food sectors is also wrong. Siloed thinking doesn't work, and apportioning blame undermines action, but we do need accountability by different sectors to each other and humanity, so everyone recognises AMR is their problem. As with climate change, it's on all our to-do lists.

Any aspects of AMR I say no to? I say no if I think it is about that organisation’s agenda, trying to make them look good rather than take action that will help, likely them, but others as well.

If you could have a full-page advert in the Financial Times, what would it say and why?

The message would have to be: “This matters to everyone, and you can do something about it.”

This matters to everyone, and you can do something about it

We really want people to understand that, and one of the ways we have been trying to make it happen is with a musical called The Mould that Changed the World. It describes the life of Alexander Fleming, who discovered penicillin, the first antibiotic, in 1928, but it is about AMR. We are taking it to Edinburgh Fringe again this summer, and to Washington in October and Atlanta in November, so part of the advert could invite people to come watch the show and learn from it.12

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