Being Chair of both Chatham House and the AMR Review, as well as leading the full-day roundtable discussion among experts to examine the impact of the AMR Review for this paper, has tested my abilities to the full.
I have often said that chairing the AMR Review was the most interesting professional challenge in my long and varied career. Not least because within our small team we felt we were having an influence and were being listened to right from the outset. During a previous review that I led for the City Growth Commission, an experienced person suggested to me that the most effective reviews are those that have policymakers trying to implement your ideas before you have even finished. I certainly felt this was true of the AMR Review, which was very gratifying.
Before we had completed the Review, the UK government took action on surveillance with the announcement of the UK Fleming Fund, and improved support for new research through the UK–China innovation fund, which is worth £50 million. AMR also found its way on to the G20 agenda as early as the 2015 G20 summit in Turkey, and in subsequent years the G20 summits in China and Germany paid considerable attention to the challenge. I also think we contributed materially to the passing of the UN political declaration on AMR in September 2016.
The two big numbers that came from our initial paper published in 2014 about the consequences of no action on antimicrobial resistance (AMR) – namely, that around the world it will cause the deaths of 10 million people a year by 2050 and result in an accumulated cost of $100 trillion for the global economy – have been widely referenced ever since. While some experts dispute our estimates, these figures continue to be cited regularly in most articles on the subject of AMR.
Now, these initiatives might have happened if our Review had not existed, but I suspect not. A number of further policy developments have occurred since our Review finished, which I also doubt would have happened without our existence. In the agricultural sphere, the Review team have been positively surprised. The UK has adopted our precise recommended target of 50 mg of antibiotics used per kilogramme of livestock body weight (which it subsequently achieved). Health ministers at the 2018 Argentina G20 released a statement that members should phase out the use of antibiotics for growth promotion in livestock, and in the past year, both China and India have announced a ban on the use of colistin in animals. Furthermore, in the US and the UK, major food producers and distributors are shifting their strategies with respect to the AMR threat, and those at the forefront of these initiatives have told me personally that it is due to our Review.
I have publicly discussed on a number of occasions that of the 10 broad areas of policy relevance highlighted in the Review – which I often term, the 10 commandments of AMR – there has been some progress on seven of them, and in three areas (diagnostics, vaccines and the market for new drugs) there has been virtually none, despite endless talk.
At the May 2019 roundtable we organized for this paper, participants were asked to score, from one to five, the progress that has been made on each of the Review’s recommendations. Unsurprisingly, average scores all tended towards the middle or lower end of that range; and, individually, I believe many of them gave scores that mirrored these middle- to lower-end values. This was a true challenge for me as chair of the roundtable and the Review, as I had quite different scores in my head. But I thought it was important that I did not try to influence the participants.
This experience reminded me of some advice I was given towards the start and end of the formal Review. One experienced adviser encouraged me to create a formal advisory group, but I quickly decided, after consulting my team, that this would not be a good idea. Instead we developed a loose set of advisers that we generally talked to individually when we needed specific advice in their areas of expertise. I believed this would be preferable to organizing collective meetings. After all, I was chosen deliberately as an outsider, a non-health, non-scientist professional, to think differently from those immersed in the AMR world. We wanted to be truly independent, especially in terms of our approach and idea creation, otherwise we would likely have come up with recommendations that had already been suggested. I had joked to Sally Davies (the chief medical officer for England) in the first weeks of the Review that, given how much the experts seemed to know about the issue, it was not immediately obvious why they needed me? But the answer soon became apparent. Towards the end of the Review, we organized meetings involving those with different expertise and were often intrigued to realize that many did not know each other.
As we were concluding the Review, the same adviser tried to encourage me to delay the publication of our final recommendations in May 2016, arguing that the then prime minister could not play a role in promoting our findings as he would be solely engaged in the EU referendum in the UK. I resisted this advice, not least because many thought there was a real possibility that the prime minister might lose. Considering the urgency of tackling AMR, I decided to take the risk and publish the Review.
I highlight these two examples to make a broader point about something I often say when talking publicly about the challenge of AMR and finding effective solutions: unless key players are prepared to behave differently and make bolder decisions, the challenge is never going to be solved, whether that be policymakers, drug companies, doctors, farmers and, ultimately, all 8 billion of us.
Let me now turn back to the seven areas where I believe there is evidence of progress. In my view, the two biggest shifts are related: the number of AMR researchers and the amount of money that is now going into early-stage research. Indeed, from what I can tell, the amount of money that has since been announced, if not completely committed yet, is already equal (if sustained) to what we said was necessary by 2021. I am not sure what more could be done here, and I applaud all those involved in making this possible for their wise judgement.
This also gives me hope that more progress can still be achieved in the other areas, so long as crucial participants are prepared to think creatively.
On public awareness, for example, where there has clearly been some progress, why don’t key organizations, such as the World Health Organization (WHO) and the UN, approach major social media companies to pursue a full-blown AMR awareness campaign with their users? In addition to approaching familiar Western companies, this strategy should also include WeChat, the Chinese social media giant, which is now trying to expand significantly in Africa.
Another idea is to persuade key governments to start allowing AMR to be cited as a cause of death on national death registers. While somewhat macabre, this would certainly communicate the fact that AMR does kill.
Progress in agriculture, although limited, has occurred sooner than I had thought possible. But there is still a long way to go. Why don’t governments of the West do more to ban the use of so-called last-resort antibiotics, just as China and India apparently have? I continue to have occasional dialogue with major food distributors and I suspect that the momentum developed, probably due to pressures from changing consumer habits, is set to continue. This is something that could lead to obvious new initiatives such as, for example, colour-labelling on food products to reflect antibiotic usage.
On cleanliness and infection control, an obvious idea that the now head of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Peter Sands, discussed with me is to encourage the International Monetary Fund to pressure all member countries to include their health systems and water and sanitation investments, along with the usual macro-economic criteria, in their regular Article IV assessments. These assessments are something countries typically take very seriously, not least because they can affect credit ratings and the markets.
While progress on surveillance and international cooperation has been made, it is clear that momentum needs to be picked up again on both.
The three areas where there has been no progress are remarkably disappointing, given how much attention we paid to them during our Review and how often AMR circles discuss them, especially the commercial market for antibiotics.
At the heart of all three is the issue of money. We recommended the introduction of market entry rewards to incentivize the development of antibiotics and vaccines against critical new pathogens; and, crucially, affordable key point-of-care diagnostics. The few analysts who have studied the market-failure challenge that lies at the heart of these problems have essentially embraced this recommendation, or some variant of it.
What is missing, despite endless words, is a firm commitment of monies from governments or pharmaceutical companies. At times, I cynically suspect that – based on the experience of past epidemics – governments are waiting for the crisis to escalate to a point where they can most easily justify providing large-scale financial assistance to stimulate companies to develop the antibiotics, vaccines and diagnostics necessary to tackle AMR. Similarly – and here my cynicism is stronger – I suspect that companies that find the antibiotics business increasingly unattractive are simply adhering to their own risk-return calculations, which suggest it is worth waiting until governments panic and throw more money at the challenge than they are apparently ready to do today.
As I think the Review and some others have shown, comparisons to previous epidemics are not applicable as the consequences of continued inaction on AMR will be much more serious. We need a major government decision-maker to be decisive, and either be prepared to spend taxpayers’ money themselves or use it to change the risk-reward calculations for pharmaceutical companies. Perhaps a UK initiative on delinking payments for antibiotics from the volume of use announced earlier in 2019 might be the beginning of something serious. If not, our much-discussed ‘Pay or Play’ policy recommendation – whereby all pharmaceutical companies would be obliged to pay a charge if they do not have active antibiotic R&D programmes – is still a viable option.
I would like to thank everyone who participated in the expert roundtable and, of course, my friends at Wellcome for suggesting the idea. I hope it leads them, and others, to do as I have proposed – to think differently about their own role in the solution. I would especially like to thank and congratulate Charles Clift for the diligence and wisdom he has shown in putting this research paper together, despite having me to contend with.