World leaders have committed US$790m to fighting superbugs. These are infectious diseases that don’t respond to treatment using antibiotics – an essential defence against infections after surgery.
They are also essential in complex treatment programmes, such as chemotherapy. But antibiotics are being misused. They are often wrongly prescribed for viral diseases, such as the flu, and they are increasingly used in livestock to encourage growth. This abuse of antibiotics is leading to strains of bacteria that are resistant to all antibiotics. Without urgent action, it is estimated that antimicrobial resistance will result in 10m deaths annually by 2050.
The global commitment by all 193 members of the UN was not only timely but extraordinary. It was only the fourth time in the history of the organisation that the general assembly had met to discuss a health issue. While there has been a lot of excitement about the agreement, I can’t help feeling underwhelmed. First, the sum of money earmarked to tackle the problem is wholly inadequate. Second, the plan relies on domestic surveillance systems to identify new forms of resistance, even though these systems are substandard in many developing countries. Third, despite this agreement, there is scant incentive for pharmaceutical companies to produce new antibiotics.
Not nearly enough
The things the plan needs to succeed – better surveillance systems, new drugs, and awareness campaigns about the dangers of misusing antibiotics – will need enormous resources. The O’Neill review was commissioned by the UK government in 2014 to analyse the problem of antimicrobial resistance. Led by Jim O'Neill, an economist, the report estimated that it would cost at least US$40 billion to fix the problem. By comparison, US$790m is almost risible.
Both parties agree that money should be spent on better surveillance systems and sanitation in developing countries; better regulatory systems; public health awareness campaigns; better pay for infectious disease doctors; and technological improvements, such as innovative diagnostic equipment and money to fund the development of vaccines.
While the O'Neill and UN plans broadly agree on the interventions needed, the UN allocated far less money and did not include proposals on incentives for pharmaceuticals companies. The O'Neill report proposed fines for pharmaceuticals firms that don’t cooperate with governments in order to produce new antibiotics. Also, the O'Neill report proposed that countries set targets to curb the over-use of antibiotics.
The global surveillance system relies on countries sharing information on cases of suspected antibiotic resistance and rates of domestic antibiotics use with the World Health Organisation (WHO) which then monitors the global situation and identifies new global trends of resistance as well as geographical variations. A good surveillance system helps the WHO to regularly update diagnostic and treatment guidelines based on strong scientific evidence.
However, getting reliable data is not always easy. While some countries may be willing to share their data, many – particularly developing countries – have inadequate surveillance systems. Weak systems make it hard for them to identify and counter public health emergencies, let alone routine monitoring of resistance and abuse of antibiotics.
Giving Big Pharma a fillip
One of the main reasons for the antimicrobial-resistance crisis is that pharmaceutical companies have not been investing in developing new antibiotics. As the director general of the WHO, Margaret Chan, noted, only two new classes of antibiotics have reached the market in the last 50 years.
Unless we give pharmaceuticals companies a lot more money, they won’t develop new antibiotics. This is because antibiotics tend to be consumed for a short time, so the return on these drugs is much lower than for drugs for chronic conditions, such as type 2 diabetes or hypertension. The O'Neill report proposed that world leaders commit one billion US dollars to “market entry rewards” – compensation to pharmaceuticals firms for developing unprofitable drugs.
Now that there is growing resistance to antibiotics, doctors are also being urged to avoid prescribing new antibiotics unless they have exhausted all the other available options. Pharmaceutical companies are therefore wary of investing in developing drugs of last resort – drugs whose patents may expire before they have recouped the cost of developing them.
Many pharmaceutical companies are complicit in this crisis because – despite the lack of investment – the powerful pharmaceutical lobby works hard to ensure that governments do not close loopholes that would restrict the widespread use of existing antibiotics. In the US, 70% of antibiotics are used to promote growth in animals. This is a very lucrative market for pharmaceutical companies. Giving them routinely to animals vastly increases their use and the UN’s plan does not address this crucial issue.
Any international agreement that fails to deal with the underlying model of how we research and develop new antibiotics, or how they are used, has little chance of success.