The UK's five-year strategy for combatting antimicrobial resistance, published today, has been some time in gestation. While it is welcome, the delay in publication and the vagueness of the commitments illustrates the difficulties of getting to grips with antimicrobial resistance (AMR). The role of developing countries is also underplayed.
Recognition of the significance of AMR – where bacteria, viruses and other microbes outsmart the drugs used against them – is almost as old as antimicrobials themselves. Alexander Fleming noted in his 1945 Nobel lecture, two years after the use of penicillin had become widespread, that development of resistance would be inevitable, and the first case in a patient was recorded in 1947.
But the world has been slow to recognize the scale of the problem and to act on it as drug after drug encounters resistance, and too few alternative treatments are coming forward. For example, past decades have seen the loss of three classes of antibiotics for gonorrhoea. Apart from the obvious threat to the treatment of such common infections, much modern surgery would become impossible if infections cannot be treated; cancer chemotherapy and organ transplantation would no longer be viable. This is now a real risk, as bacteria continue to develop resistance while the flow of new antibiotics has diminished.
It is in this context that the new strategy has been devised. The Department of Health held a consultation on what was then a 'Strategy' accompanied by a quite detailed 'Action Plan' in October last year. The document as now published is substantially different. Notably it is now an integrated strategy which has as a centrepiece seven key areas for future action. These are described in broad terms under the following headings:
- improving infection prevention and control practices
- optimizing prescribing practice
- improving professional education, training and public engagement
- developing new drugs, treatments and diagnostics
- better access to and use of surveillance data
- better identification and prioritization of AMR research needs
- strengthened international collaboration.
Translating these very broad objectives into 'an agreed work programme…with timescales for delivery of specific actions' and 'detailed outcome metrics' will be the job of a new Interdepartmental High-Level Steering Group. The work plan is to be published by April 2014.
Developing an action plan – involving multiple partners in the health service, regulators, the veterinary sector, the research councils, the devolved governments and others outside government – is clearly a complex process, which is no doubt why publishing a credible plan at this stage must have been problematic. This is symptomatic of the difficulties of tackling a problem such as AMR where so many actors with widely differing motivations need to change their behaviour for there to be a success. Nevertheless, it is hoped that an interdepartmental group can deliver what the interdepartmental team working on the strategy could not: but the track record of such groups is mixed.
Since taking office, the UK's Chief Medical Officer Professor Dame Sally Davies has made a point of recognizing the international dimensions of the AMR problem and the need for coordinated action. The strategy notes the efforts of the UK to promote AMR on the agenda of the World Health Organization (WHO), where she has had some success; and of the G8, where a meeting of science ministers endorsed coordinated action but it was not reflected in the final G8 communiqué. It also makes clear the scale of her international ambitions – including considering 'the need for a future international treaty to protect special medicines like antibiotics'.
This part of the strategy invites two particular comments. It fails to note, as a meeting of veterinarians and physicians did last year, that the 'probability that selection for resistance will occur where antimicrobial usage is highest and least controlled, coupled with unprecedented mobility of humans, means that, whether AMR originates from animal use or human use, the threats in Britain and in Europe will often emanate from outside. Strategies in the UK in human and veterinary medicine must recognise this.' This would suggest the need to focus on what is probably the most intractable problem – how to control use in developing countries. This angle is at best implicit in the document which entirely omits any specific reference to developing countries.
This also illustrates a second challenge. The text is rich with calls for action of various kinds but the content of that action is rarely defined – process trumps content. So it is good that the UK is to take 'a leading role in development of a new AMR resolution in the World Health Assembly' but it would be better if there was a definition of what precisely that resolution should ask of member states, in particular developing countries, and WHO. Similarly the UK will be 'supporting efforts to strengthen international partnerships and coalitions to facilitate the development of new antibiotics' but the really difficult question is what concrete policies would be best to address the problem of new drug development?
Chatham House is running a series of roundtables and a conference on AMR issues.