Politicians, doctors, scientists, farmers and other experts met in Westminster yesterday for the Bureau’s summit on how to tackle the global superbug crisis. We launched our new microsite at the same time.
Antimicrobial resistance (AMR), which is when bacteria, fungi, viruses and other microbes become resistant to the drugs used to treat them, has been called the biggest global health threat the world faces. The event sought to put it on the political agenda and raise awareness to the problem in developing countries.
The event was sponsored and introduced by Kevin Hollinrake MP, who has campaigned on the issue of AMR. It was chaired by the Bureau’s managing editor, Rachel Oldroyd.
It began with a video message (above) from Professor Dame Sally Davies, England’s Chief Medical Officer, who said that AMR is a problem without a face because most patients aren’t told they have a resistant infection. Commenting on the Bureau’s story about critically important antibiotics being used to make chickens fatter, she called for an end to drugs being used for growth promotion within five years.
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Lord Jim O’Neill, a former finance minister and economist who chaired the government’s review into AMR, began the discussion with a speech on the progress that has been made since his report was published in 2016. He said that there had been a lack of action in three areas: pharmaceutical companies developing new antibiotics, new diagnostic tests, and using vaccines in livestock to mitigate use of antibiotics.
New diagnostic tests are a “game-changer”, he said, adding that by 2020 all governments should make it mandatory that doctors only prescribe antibiotics if a patient’s infection has been diagnosed by a state-of-the-art test.
He called for more transparency from drug companies around antibiotic effluent released as part of drug manufacturing. In his report he called on governments and pharmaceutical companies to provide $40 billion to tackle the threat of AMR. “That’s a lot of money until you realise pharma companies have already spent that buying their own shares”, he said.
He also cited the “irritating” power of the food, pharmaceutical, and agricultural lobbies and urged governments to face up to it. In response to a question about the Bureau’s story about colistin - an antibiotic crucial in human medicine - being used as a growth promoter in farming in India, he said all antibiotics important in human medicine should be banned in agriculture.
He finished his speech with a plea for the UK to start leading on the issue again. “Under David Cameron we were [world leaders]”, he said. “Everywhere I went in the world big important people would say ‘wow, what the UK has decided to do on this is fantastic’. We need to get back to that same level of voice to make sure the momentum that is going on is not only maintained but accelerated.”
Dr Thomas Van Boeckel, a scientist at the Swiss University, ETH Zurich, who has mapped the use of antibiotics in animals worldwide, spoke next. He said the reduction of antimicrobial use in animals in the UK was “remarkable” but that this was in stark contrast to the situation across the globe, where consumption is set to increase. He described three policy options he had modelled. The first was to impose the equivalent of the UK target for antibiotic consumption in animals - 50mg /kg meat - on the rest of the world. The second was to reduce global meat consumption to average levels of Europe, and to reach this by 2030 (which could also have other health benefits). However, those policies rely on voluntary measures or compliance with regulations, which could be impossible in areas of the world where veterinary experience is limited, he said.
The third proposal was to introduce a fee on animals reared on antibiotics; not to prevent the treatment of sick animals but to make using antibiotics as a surrogate for clean farming practices unviable. “The real tragedy of AMR is that millions of people do not have access to antibiotics because they cannot afford it”, he said. “When these people will finally be able to afford antibiotics they will not work. Not because they misused it, but because we did. And because we used a lot of it to raise chicken and pigs.”
Next, Dr James Tibenderana, global technical director at the Malaria Consortium, which runs health programmes around the world, began his speech with a story of a Ugandan child who was unconscious with a high fever due to meningitis. The patient's family had come a long way to the hospital and couldn’t afford the antibiotic needed. Besides, it wasn’t on the hospital’s essential medicine list. Dr Tibenderana said he broke with what is considered good practice and called a local pharmacy in case they had the antibiotic. The child’s father rushed out to get it. Fortunately, the child survived. Dr Tibenderana said clinicians around the world now face similar, or more dramatic, circumstances due to antibiotic resistance.
Overuse is common in African and Asia, where malaria resistance, HIV resistance and TB resistance is occurring. To tackle the problem we need to raise awareness among the public and health workers, to make people understand why antibiotic resistance is important to them. We also need to sensitise governments to the effects AMR could have on their country’s economic development, which might increase funding for it, he added. Public-private partnerships, such as the Global Fund, a scheme which funds local programmes to prevent AIDS, tuberculosis and malaria, should also be explored. “Business as usual is not an option”, he said.
Dr Clare Chandler, a medical anthropologist who runs the AMR Centre at London School of Medicine and Tropical Hygiene, and has worked on medicine use around the world for over fifteen years, described how antibiotics are equated with good healthcare in the UK and many parts of the world. In some places, for example, health care centres close if there are no drugs. “If you don’t receive a medicine, care is not thought to have been fully performed”, she said.
Interventions can also have unintended consequences, she said. Her work showed that in some countries when malaria tests were introduced, doctors still felt compelled to give antimalarials. In other places they reduced antimalarial use but antibiotic prescriptions rose. In another country, she observed that health workers shifted their perceptions of patients in light of the test. Health workers began to see patients who didn’t “pass” the clinical test as undeserving, even if they were ill with a fever, or they focused on the test over other illnesses. One Ugandan mother said: “It was all very well to talk about the fever but the health worker ignored the hernia my child had.”
She also talked about how our use of antibiotics is related to the wider political and economic context. Antibiotics speed up recovery so that people can get back to work more quickly, and increase productivity. Antibiotics are important for day wage labourers, for example, who cannot afford to miss a day of work, she said.
“If we are using an antimicrobial as a way of allowing people to go back to work we are seeing people as a productive unit and productivity as something that is important. Each animal is a productive unit, we cannot afford to let an animal die when we could save it with an antibiotic.” If antibiotics start becoming ineffective, or in order to stop using them so that this doesn’t happen, we need to think about what matters in life, she said. “We need to be able to find other ways to perform care, or be productive, or accept that we will have lower productivity.”
The panelists took questions from the audience. One audience member raised the issue of unintended consequences of the AMR agenda - including the possible prevention of long-term treatment for women with chronic urinary tract infections. Another asked whether the money governments are spending on superbugs is going to the right places. Dr Tibenderana’s plea was one of the most poignant as the panelists summed up their remarks. “We need to stop talking about the problem,” he said. “We need to start acting.”
Header image of the panel, by Rob Stothard
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