The HealthSense Award 2022 went to a leading figure in global health, Dame Sally Davies. Founder of the National Institute of Health Research (NIHR) and past Chief Medical Officer for England and Senior Medical Advisor to the UK Government, Dame Sally told HealthSense members, "I am honoured to receive this important award. Important because of the focus on evidence and communication with the public."
The following is the text of her talk, given at the HealthSense AGM held at the Victory Services Club, London, on 30 November 2022. The full recording of the HealthSense 2022 awards, including this presentation, can be experienced on the HealthSense YouTube channel.
I have been advocating for global action on anti-microbial resistance (AMR) for almost a decade, including as the United Kingdom’s Chief Medical Officer from 2011 to 2019. In that role I led the Ebola response, oversaw the Novichok tragedy, and introduced the sugar levy to tackle obesity.
Yet, it is AMR that remains my and the world’s biggest challenge.
We in the UK have made good progress on tackling AMR to date. Our One Health Action Plan on AMR is now being updated while the EU has recently enacted ground-breaking legislation to ban the use of antibiotics as growth promoters for food-producing animals.
The efforts of policymakers, researchers, industry, and healthcare workers have never been more necessary. We are seeing globally the impacts of an initially untreatable infection. But it is clear that COVID-19 will not be the last pandemic that our world will face. It might be easy to ignore the quieter pandemic of AMR, but we know that without effective antibiotics, our health, food and environment systems, and economies, would grind to a halt.
AMR a bigger killer than HIV, TB or malaria
Earlier this year, the world’s first and most comprehensive estimates of the global burden of AMR to date were published. Researchers from Oxford University and the Institute of Health Metrics and Evaluation at the University of Washington analysed 204 countries and 471 million individual health records to reveal truly harrowing data. Over 1.2 million deaths were directly attributed to AMR in 2019 – making bacterial AMR a bigger killer than HIV, TB, or malaria.
Whilst the highest burden of AMR was beyond the borders of Europe and North America, this is a problem for all of us. We will all bear the social and economic costs of AMR if we do not work together to contain and control it. Of note, Methicillin-resistant S. aureus remains a significant global burden but is not on the WHO’s priority list for developing new and effective antibiotic treatments. So, this new data must be a wake-up call to the world for how and where we must target and tackle infections.
With the bleak picture these data depict, we have got to use evidence to inform our national and regional actions. It is especially important that we can point to the impact of AMR on our interconnected systems, with AMR both driving and being driven by negative externalities across human, animal, and environmental health systems.
Antibiotic-polluted rivers
In fact, this year saw a new major study of over 250 rivers from over 100 countries found that over one quarter of these rivers were polluted to toxic levels from antibiotic residues. Madrid has the most polluted river in Europe, ranking in the top 10 per cent of global places with the highest cumulative concentrations of Active Pharmaceutical Ingredients. Glasgow also came in the top 20 per cent globally.
The insights from this study can and should help incentivise action at local, national, regional, and global levels. We’ll need to invest smartly for the future and invest in systemic solutions, such as infection prevention and control; improved sanitation and access to water; and R&D for diagnostics, novel therapeutics, and vaccines. And the interventions and infrastructure that we need to tackle AMR will also build our capability to tackle other future global challenges, including pandemics.
We can no longer afford to mortgage the future of our planet by running our medicine cabinets empty, toxifying the environment, or intensively farming animals in breeding grounds of infection. If we want a sustainable and secure future, then we need to mobilise for solutions now.
Most new antibiotics are not available in all parts of the world
Let us start with research and development. The global scientific community was able to develop COVID-19 vaccines rapidly because they were built on years of earlier investment and research. But, as it stands, most new antibiotics are not available in all parts of the world. Of the 25 new chemical entities developed between 1999 and 2014, only twelve had registered sales in more than ten countries. Countries even in Europe do not benefit from novel antibiotics, because country-by-country registration is too costly.
If we need a new antibiotic tomorrow, the ship has already sailed. Only five of the twelve antibiotics companies that have gone public in the last decade are still active.
It is an unviable market for large companies, let alone for Small and Medium Sized Enterprises, who account for 75% of all late-stage antibiotics in the R&D pipeline. Because of their limited funding, these SMEs understandably channel most of their efforts into discovering and developing new products. This leaves little for commercialisation and distribution – only 25% of late-stage antibiotic projects have stewardship and access plans. An analysis of European public funding indicated that 86% of national-level funding for antibiotics was directed at basic research – leaving a glaring gap for the SMEs who develop this research into usable, and potentially accessible, products.
"The world is failing on AMR"
That’s why the WHO have said that ‘the world is failing on AMR’. Last year, I laid this out loud and clear to the Health Ministers and Commissioner of the G7. I challenged them to work together, and to work with industry and their Finance Ministerial colleagues to balance innovation, access, and stewardship. I urged them to build on the advances made in R&D for COVID-19 by acting strongly, and across disciplines.
So, to address these economic problems the G7 countries, including the EU, are seeking to improve the market conditions for antibiotic development. Our G7 Finance Ministers made commitments on AMR for the first time ever – emphasising the role of pull incentives that could be piloted across their economies and health systems, designed to ensure a sustainable pipeline of new and equitably accessible antimicrobials.
We'll be driving forward progress that is already starting to be made, like Germany's reimbursement model and Sweden's access pilot. In the UK, our innovative 'Netflix model' is a world-first system to pay for antibiotics by subscription – based on their value to society, not on the volume of pills used. This approach benefits NHS patients by guaranteeing both sustainable use and sustainable supply of antibiotics – by embedding stewardship and by giving companies certainty of demand. Following a rigorous process with expert clinical input, two treatments – Cefiderocol (Fetcroja) manufactured by Shionogi, and ceftazidime with avibactam (Zavicefta) manufactured by Pfizer – have been signed under contract and will now be available to patients in the UK.
Tipping point
With the PASTEUR Act also in the US Congress, we are reaching a tipping point where big markets can show industry that antibiotic R&D is worth it. I am also delighted that the G7 has committed to build knowledge about AMR in the environment and explore international standards on the safe concentrations of antimicrobials released into the environment from pharmaceutical manufacturing or from healthcare facilities. More research, evidence, and monitoring of the impact of AMR on climate change is needed – and we need industry to step up and play their part to ensure compliance with safe limits of antibiotic pollution too.
You know as well as I do that every day counts in a pandemic. It is so important to have surveillance producing data that is openly accessibly. That’s why our UK Fleming Fund is a major international aid investment dedicated to AMR is supporting countries across Africa and Southeast Asia to build laboratory capacity, infrastructure, and capability to generate data, share data and use data to inform national and global decision-making.
Across 24 countries, we are bringing evidence and people together to support countries with laboratory equipment and skills. For politicians and policymakers, accessible data provides an understanding and ownership of the challenge. On the ground, data empowers healthcare workers with the tools they need to drive solutions that work for the context they are facing.
A "One Health" approach
Through the UN Global Leaders Group, we are working to ensure that AMR, including surveillance, is embedded in any future pandemic legal instrument that countries are currently negotiating. The Global Leaders Group is pushing for this accord to take a ‘One Health’ approach that benefits AMR too. We do not know what the next pandemic will be, but it could well be drug-resistant, or depend on antibiotics to treat hospitalised patients with secondary bacterial infections. So, if we have legal obligations for surveillance – these should be like Christmas tree lights: always shining and working for AMR, but then flashing and pivoting when an outbreak occurs. We also need to ensure that equitable access underpins any provisions here.
This multi-sectoral approach is so important because 80% of antibiotics are used in animals, rather than for humans. I am also proud that new data released last week shows that sales of veterinary antibiotics in food-producing animals in the UK is at its lowest ever recorded figure. Since 2014, we have seen an 83% decrease in the sales of antibiotics which are of critical importance in human health. We too are committed to reducing unnecessary use of antibiotics in animals and it remains our intention to strengthen our national law in this area, including around prophylaxis.
We can't underestimate the role of investors and industry in this too. McDonald’s have announced a policy to eliminate the use of the Highest Priority Critically Important Antibiotics, as defined by the WHO, in their chicken by 2027. We need this to remain on track, or even accelerate. As more people take an active interest in the ethics of their food, more companies are willing to act — or at least pressured into acting for fear of losing their reputation.
Pressuring shareholders and investors
I have even been working with my students from Trinity College, Cambridge to advocate for the responsible use of the university’s endowment fund. They have gone to the AGMs of YUM!, which is the parent company of KFC, McDonald’s, and Pizza Hut, to pressure their shareholders to agree to carry out a gap analysis that would report on the use of antibiotics in its supply chains. As a result, YUM! became the first public company to agree to disclose its impact on the broad economy and diversified shareholders. This is real leadership from the youth, and I hope you will join us and encourage other students to take a stand here.
From the UK, we have launched the Investor Action on AMR initiative. We are calling on investors to commit to making sustainable investments and align with global best practices on AMR by incorporating AMR into their ESG standards. To date, 15 investors from across the world with a collective asset portfolio of over $11 trillion have signed up. We would love to see more investors from across the EU join us.
The global response needs commitment and action from everyone, everywhere. The AMR community is strong, but there is plenty of room for more people to join us. Despite the growing political action on AMR, there is still inequity in access to knowledge and education about AMR. Public engagement does not currently match the scale of the threat, and this will directly impact our ability to change behaviours and policies.
The Mould that Changed the World
Recently, I was in Washington D.C., where I am delighted to have supported a truly out-of-the-box solution to the extraordinary problem of AMR. We staged the musical, The Mould That Changed The World, in a local theatre to audiences in their hundreds. Using creative storytelling and song, the musical tells the story of Alexander Fleming’s life and his discovery of penicillin – and the eventual human toll of resistance.
By marrying the arts and the sciences, the musical is bringing new audiences into a movement for change. Alongside professional actors, local healthcare workers, microbiologists, science teachers or STEM students will perform in the chorus – giving these trusted members of local communities a platform and creating credible local champions for AMR. There is also a version for children to put on, with free resources for them to learn catchy songs and dances about the importance of cleaning their hands.
The musical has just last night finished its run in the US, and now we hope to secure funding to bring this amazing project it to other cities around Europe and the world too.
Mobilise networks
This is now more critical than ever, because in 2024, we will see a High-Level Meeting on AMR at the UN General Assembly in New York. This will be a crucial moment for global leaders, civil society, and industry to come together and commit to actions that take us forward. Together, we can build on the 2016 Political Declaration, whilst learning lessons from climate change and from the COVID-19 pandemic. We look to all of you to mobilise your networks to contribute to the conversation leading up to 2024, and to show leadership inside and outside of UN debating chambers.
The achievements of the past few years for COVID-19 vaccines are inspiring and unparalleled – and hopefully bode for further innovations for the AMR pandemic. I also hope that more young people, including women, will be inspired to take a career path in science, diplomacy, and policymaking too, and bring their voices to the table.
Globally, we have a short window in which to build forward from COVID-19, with equity at the heart. We need to work together to realise our vision of a world free of drug-resistant infections- and I look to all of you hear today to help on this.
This is how we use evidence and creativity in the war against AMR.
Dame Sally Davies
UK's Special Envoy on Antimicrobial Resistance, a Member of the United Nations Global Leaders Group on AMR