A beginner's guide to a global health crisis: AMR
“The era of procrastination, of half-measures, of soothing and baffling expedients, of delays is coming to its close. In its place we are entering a period of consequences.”
— WINSTON CHURCHILL, 1936
Have you ever considered the prospect of dying from a bloodstream infection caused by a raging STI?
No?
What about a never-ending case of debilitating diarrhoea?
Still no?
How about a future where a small cut could kill, a future where life-saving surgeries, joint-replacement operations and chemotherapy become too risky to undertake – a future where all modern medical methods are exceptionally high-risk and can no longer be performed?
Again, no? Well, all of these outcomes are connected. Whether it be through a patient demanding a doctor unnecessarily provide a prescription, said doctor acquiescing arbitrarily to the demands of the patient, a farmer lumping liberal amounts of additives to their livestock’s feed, a person in a developing country being handed a cocktail of unknown drugs for a common cold, this futuristic medical dystopia illuminates one treacherous truth; we are in the midst of a global health crisis.
Based on low-estimates made in 2014, this very same global health crisis is currently responsible for 700,000 deaths per year. By the year 2030, it is projected to place 24 million people in the ‘extreme poverty’ bracket. It is predicted that it will reduce the world’s GDP (gross domestic product) by 2%-3.5%. That equates to USD $100 trillion.
By 2050, it is expected to kill 10 million people per year. That is one person every three seconds.
Bluntly assessed by General Practitioner Dr Chris Moy, the Federal Chair of the Ethics and Medico Legal Committee of the Australian Medical Association: “it’s a massive issue. We’ve really, in simple terms, fucked it up. We’ve acted like millionaires for too long, and we need to sort it out”.
“Antimicrobial resistance will affect everybody, regardless of where they live, their health, economic circumstances, lifestyle or behaviour.” — WORLD HEALTH ORGANISATION, 2015
READ: The Review on Antimicrobial Resistance, Chaired by Jim O’Neill
This global health crisis is antimicrobial resistance, or AMR. AMR occurs when a pathogen – that is, a microorganism that causes disease - becomes resistant to the drugs we use to treat them. What must be understood is that resistance occurs naturally; pathogens are living things, and thus possess the capability to evolve. What research is showing, however, is that excessive use and misuse of antimicrobials is accelerating resistance across the globe.
Jim O'Neill's Review on AMR (2014 modelling).
Antimicrobial Resistance in Australia
Amongst the biggest issues the world is facing in the fight against AMR is a lack of new antimicrobials, education of the issue and an implementation of global standards to ensure the misuse of antimicrobials, both agriculturally and medically, is eradicated. This was established in 2015 with the World Health Organisation’s ‘Global Action Plan on Antimicrobial Resistance’. On March 13th this year, the Council of Australian Governments endorsed its new, second AMR strategy.
READ: Australia’s National Antimicrobial Resistance Strategy, 2020 and Beyond
There is no mention of the Northern Territory, Central Australia, or its ongoing battle with methicillin-resistant Staphylococcus aureus (MRSA). The 2019 AURA (Antimicrobial Usage and Resistance in Australia) report indicated that, in 2017, MRSA was on the rise in ‘very remote’ areas, with 40.2% of S. aureus isolates being resistant to methicillin in this area. ‘Remote’ areas reported 40.6% as being resistant. Australia does not yet monitor MRSA through a specific surveillance body – when it comes to observing and reporting on resistances of note, the general consensus is that surveillance systems are vital, rather than one off studies from select medical outlets.
READ: Antibiotic Resistance is an Even Greater Challenge in Remote Indigenous Communities
“The other thing that’s scary is it’s not just medical,” says Moy. “It’s agricultural as well – we’ve got to sort that out. It’s a disaster area of major proportion.”
It is clear from the strategy that Australia does not monitor resistance or usage levels among animals and the general agriculture industry through a federally funded surveillance system, instead choosing to rely on each individual sector surveying themselves and reporting their own data back to the Department of Agriculture. As a general practice, the agriculture industry uses antibiotics as growth hormones and prophylactically in plants.
Unlike a virus, bacteria don’t need a living host; they can survive on their own. If a resistant strain of bacteria grows inside an animal, there is every chance it can end up on supermarket shelves and pass on to humans. Consider the following: the OIE (World Organisation for Animal Health) estimate that 60% of current pathogens are zoonotic; Australia is the second-largest exporter of beef in the world with China and Japan as the two largest contributors; Australia is the largest exporter of sheepmeat in the world, with 70,000 tonnes going to China and 20,000 tonnes going to Malaysia; by 2050, 4.7 million people in Asia are predicted to die because of AMR. It is becoming essential to monitor AMR in the animal and agriculture industry so as not to excessively exacerbate another nation or region's resistance problems.
However, what should be highlighted is that Australia’s antibiotic usage amongst the agriculture industry is quite low. Relative to the rest of the world, it ranked the fifth lowest out of 29 countries surveyed back in 2015. It is also worth bearing in mind which comments are coming from which sector – because, as Data Analyst at the Oxford Global Burden of Disease, Georgina Haines-Woodhouse, puts it: “it’s easier to kind of shit on farmers than acknowledge that misuse amongst humans is the problem”.
“Only through a shared responsibility in the health, agriculture and environment portfolios can a national antimicrobial resistance effort succeed.” — AUSTRALIA’S NATIONAL ANTIMICROBIAL RESISTANCE PLAN, 2020 AND BEYOND
When it comes to the misuse of antimicrobials amongst humans in Australia, the problem is very real. Every other month, the CARAlert (National Alert System for Critical Antimicrobial Resistances) produces a report on the resistances reaching critical levels in Australia. The latest report using pre-COVID-19 data (from the 1st of January to the 29th of February) indicated there was a 10.8% increase in critical AMRs compared to its predecessor.
Shigella species, a close relative of E. coli (which causes bowel infections and the aforementioned explosive diarrhoea), reported 27.6% of isolates were multi-drug resistant, with a 127% annual increase. N. gonorrhoeae reported a 38% increase in isolates that were non-susceptible (showing mild signs of resistance) to azithromycin, the recommended oral antibiotic for gonorrhoea. Carbapenemase-producing Enterobacterales reported a 36.6% increase. Carbapenems are last resort drugs. Last resort drugs are used if all else fails; if they start to fail, humanity becomes extremely vulnerable to all infections.
Research also shows Australia is considerably lacking in education surrounding the issue of AMR. In a news release from the 14th of May, a recent CSIRO commissioned survey found that, of 2217 people surveyed, 92% did not know the difference between a viral and bacterial infection and 14% use antibiotics prophylactically (“just in case”) when travelling overseas. A further 19% believed that antibiotics were essential for a common cold.
READ: Why No Amount of Antibiotics Will Help Get Rid of Your Cold
“Communication, education and training are not only crucial to creating deeper awareness and understanding of the challenge, but vital in empowering communities to take ownership of the issue.” — AUSTRALIA’S NATIONAL ANTIMICROBIAL RESISTANCE PLAN, 2020 AND BEYOND
Assertively, General Practitioner Moy states: “patients are half the problem; they’re coming in and demanding it, and it’s due to general education”.
“If you’ve got a ten minute appointment and they come in and you’ve got a rush and you’ve got a person who’s got no idea about it, you’ve got two choices; try and provide them with an education, or you can write them a script. And sometimes, you’ve got to balance it all up. It’s not great,” he admits.
The data compounds the statement that the issue is, indeed, not great.
READ: 2018 NAPS Aged-Care, Hospital and Surgical Report
In the Aged-Care report, a 1.2% rise in prescriptions was observed, with 58.9% of prescriptions missing a documented review or stop date, and 25.1% of prescriptions providing no documentation of identification. A review or stop date is essential in prescribing antimicrobials as it indicates when an infection can be expected to be killed off. If an infection isn’t killed off in its entirety, it increases the chance for resistant pathogens to grow back into the vacated space. If antimicrobials are used for too long, it starts to kill off the good bacteria responsible for fighting infections in the gut and again leaves room for resistant bacteria to grow in its absence. When bad bacteria invade, the resistant bacteria are able to ‘share’ their DNA structure with the bad bacteria, and create a new resistant pathogen.
Image: Centers for Disease Control and Prevention USA
According to the Hospital sector’s report, documentation of indication - why the antimicrobial is being prescribed - in public hospitals sat at 84.4%. Private hospitals returned a rate of 64.5%. The best-practice target is 95%.
The same best-practice target of 95% is applied for the documentation of review or stop-date in the Hospital sector. Only 45% of prescriptions fulfilled could provide the documentation.
READ: Why Is Finishing Antibiotics So Important?
Furthermore, it also reported that, in the hospital sector, 25.7% of prescriptions were deemed “non-compliant” with pre-established guidelines; 21.4% of prescriptions were “assessed as inappropriate”. A further 10% were assessed as inadequate - which, according to the 2018 NAPS, “is disappointing as this category should be approaching zero” - something Moy states is “not a matter of ethics”, but a “matter of clinical appropriateness”. “[Patients] need to understand there’s no requirement for doctors to prescribe anything,” he says.
But, as Moy adds: “we might get our act together, but then in another country which doesn’t have the education and it’s easier to hand out a script…we’re going to have the same problem and it’s going to come back to Australia”.
The Global Aspect
“There’s a huge issue in Asia where they don’t understand what antibiotics are. If they get ill, they’ll want antibiotics no matter if it’s a bacteria or a virus.” — GEORGINA HAINES-WOODHOUSE: DATA ANALYST, GRAM, OXFORD GBD
This is a global health crisis. Every country around the world is experiencing their own individual problems, but the only way to effectively tackle AMR is through a concerted global effort to work together.
The first problem with this is actually getting global Governments to work collaboratively. Considering the world’s recent efforts with COVID-19 - which, to date, resulted in the USA pulling out of the WHO, diplomatic relations between countries such as Australia and China plummeting and the governing health body of the world needing to pander to the Chinese Government just to access crucial data - optimism cannot be high because, as Haines-Woodhouse asserts, data is “very diplomatic” and “hugely political”.
“I don’t feel like the top levels will work together,” she says. “But there are a lot of research groups and people lower down the totem pole that are excited to work together.”
“If you bypass the top level – because, that’s just men having a pissing contest basically – people are willing to work together.” — GEORGINA HAINES-WOODHOUSE
It’s a sentiment that is being echoed across sectors. On the topic of Governments working together, Moy says, “I’m not betting on it”, whilst a representative from a pharmaceutical company said despite there being “a lot of alliances” forming in the pharmaceutical industry globally, it was “important to educate MPs” about AMR.
“This is what’s really frustrating for me,” states Haines-Woodhouse. “People don’t seem to be able to get over themselves to work towards the greater good…there’s always a vested interest, a ‘what can I get out of this?’. It’s not an ideal world.”
Working in the Oxford Global Burden of Disease (GBD), Haines-Woodhouse – on top of completing a Masters degree in Research, Ecology, Evolution and Development – holds a unique insight into the global effects and problems of AMR. Currently, she is working as a Data Analyst in the GBD’s flagship project GRAM: Global Research on Antimicrobial Resistance.
Established in 2018, GRAM is currently one of two global initiatives dedicated to AMR. The other is the WHO’s project GLASS – Global Antimicrobial Resistance Surveillance System – which was established in late 2015. Both projects were inspired by Jim O’Neill’s initial 2014 economic review on AMR.
Countries enrolled in reporting AMR to GLASS. (Image: GLASS/WHO)
The two projects differ in their focus: GLASS, who are doing “vital work” according to Haines-Woodhouse, monitors a much smaller pool of drug, bacteria and disease combinations in an attempt to understand the prevalence of AMR. At GRAM, the mindset is directed towards calculating the eventual global burden of resistance through, amongst other things, combining data collated about excess mortality, case fatality rates, the prevalence of resistance itself and disability-adjusted life years. The purpose of projects such as these is to calculate the burden of AMR globally, to highlight and monitor the rise in different resistances and pathogens globally, and provide a baseline level of data to give different areas of the world specific feedback on what they need to improve on.
“There’s never been one pool of data to say you (a nation) might want to focus on these bacteria, or this specific bacterium-drug combination because you’re having a massive issue,” she says.
“Surveillance systems are vital, and that’s one of the main aims of the project – particularly in developing countries, but also make developed countries aware they need to sort their system out.” — GEORGINA HAINES-WOODHOUSE
However, as mentioned before, data is used as a negotiating tool between nations and governing bodies, and occasionally exerts huge political ramifications for a nation’s global image – it's not just the BRIC countries, developing countries, or developed countries that try to save face when it comes to divulging data sets. It's all of the above.
This immediately impedes any global effort to calculate the prevalence or burden of resistance, and transparency from all nations must be improved if the world is to work together under the ‘One Health’ strategy outlined by the WHO.
“It’s all about optics,” says Haines-Woodhouse with an air of frustration. “If a nation is up-and-coming, they don’t want to be seen to have this massive issue with resistance.”
The Problematic Pathogens
One particular pathogen that’s beginning to create havoc globally is gonorrhoea. In the GLASS 2020 Early Implementation report, the median level of resistance to ciprofloxacin (antibiotic used to treat gonorrhoea) by Neisseria gonorrhoeae isolates was just under 60%. Just under 5% of N. gonorrhoeae isolates showed resistance to the aforementioned azithromycin; however both Croatia and Nepal reported extreme outliers of 60% and 63.6% respectively.
WATCH: GLASS 2020 Early Implementation Report
The problem with gonorrhoea is actually owning up to the issue. In the GLASS report, out of 78 countries that submitted reports, only 32 provided data on resistant strains of gonorrhoea. Not providing data is a symbol of denial; for example, Madagascar submitted a data set that showed 0% of isolates were resistant to azithromycin, but 100% were resistant to ciprofloxacin. A data set that shows no level of resistance is still of the utmost importance as it allows surveillance systems to fully understand where the major problems are; allows them to understand the global severity of the issue; allows them to understand where they need to act. They are no longer in the dark.
“[Gonorrhoea] is a bit sensitive in some places,” states Haines-Woodhouse. “Some places say ‘we don’t have that here’ whereas all the other countries around them have it – so you don’t quite trust that statement.”
One of the aims of GRAM is to be able to provide feedback to countries on which drugs to use for what specific pathogen and where, because all living things evolve to develop traits they need to survive. In that exact same breath, all living things will drop traits that they don’t actually need or use anymore – and this concept is one of the key drivers behind managing AMR.
“This is why we need to know where different drugs are a problem,” says Haines-Woodhouse, “because you can then try and implement a cycle where you use one drug for a few years and then switch it up, and hopefully the resistance levels go down.”
Gonorrhoea is one of the ‘flashier’ pathogens printing headlines. But the issue is much deeper than gonorrhoea, not least because it can only cause one syndrome - an STI. AMR becomes a lot more confronting, dangerous, lethal when pathogens such as Streptococcus pneumoniae, Staphylococcus aureus and the Enterococcus species become resistant. The names are long and scientific and don’t sound familiar; but S. pneumoniae is the most common cause of pneumonia, ear infections, sinus infections, meningitis and bloodstream infections. Enterococci is a common cause of surgical wound infections, urinary tract infections and ‘nosocomial bacteremia’ – blood infections obtained within 48 hours of an operation. S. aureus is responsible for causing ulcers, wounds, pimples, endocarditis, skin infections, bone infections and toxic shock syndrome.
The buck doesn't just stop there either. HIV, tuberculosis and malaria are three of the most infamous diseases, and drug-resistant forms of each of those three are on the rise in different parts of the globe.
READ: HIV Drug Resistance Report 2019
READ: Global Tuberculosis Report 2019
READ: Interactive Malaria Drug Resistance Map
Drug resistant HIV is showing severe exponential growth in sub-Saharan Africa. According to studies, there are predicted to be approximately 890,000 deaths caused by pre-treatment drug resistant HIV (PDR) along with 450,000 new infections, as well as costing $6.5 billion from 2016 to 2030. PDR refers to resistance detected among people initiating antiretroviral therapy for the first time, or people with previous antiretroviral drug exposure re-initiating the first line treatment of HIV.
Based on nine studies from sub-Saharan African countries, over half of infants diagnosed with HIV carry a virus that is resistant to efavirenz or nevirapine. Those two drugs are used in first line treatment as NNRTIs, which are drugs used to slow down the replication of HIV cells and suppress the viral load. A successful suppression of the HIV viral load means the disease is intransmissible and undetectable. If a case is undetectable, that person can no longer pass on HIV through sex.
It’s not just the African region showing severe signs of HIVDR. In the Americas WHO Region, Argentina, Cuba, Guatemala, Honduras and Nicaragua are reporting between 10% and 30% of HIV cases as PDR to efavirenz (EFZ) and nevirapine (NVP). It is the same in the South-East Asia and Western Pacific WHO region with Nepal and Papua New Guinea.
Figure: WHO HIV Drug Resistance Report 2019
So, what happens when the first line of treatment does not work? There is a second line treatment. If that doesn’t work, there is a third line treatment.
The problem is, however, that first line treatment costs $85. Third-line treatment costs $1235. Combined with money spent on research, growing healthcare costs, longer stays in hospital and less time in the workforce, the global cost of USD $100 trillion forecast in 2014 slowly starts to take shape.
However, for all the talk of HIV, it is not even the leading cause of death from a single infectious agent – that throne belongs to tuberculosis. As it stands, tuberculosis (TB) is one of the top ten causes of death worldwide, and drug-resistant tuberculosis (DRTB) is emerging as a colossal threat in the Asian and Eastern European regions of the world. It is also important to bear in mind that TB is an opportunistic infection: meaning TB is a pathogen that takes opportunities to infect when they are not normally available – for example, in someone with a severely weakened immune system (HIV) – and thus TB related deaths among HIV-positive people are counted towards HIV.
The Global TB report from 2019 indicated that there were an estimated 484,000 new cases of rifampicin-resistant TB. Rifampicin is one of the first-line drugs used to treat TB.
Of those 484,000 cases, 27% came from India, 14% came from China, and 9% came from Russia. Of those 484,000 cases, 78% were reported to be MDR-TB – multi-drug resistant tuberculosis - with the highest proportion appearing in former Soviet Union countries. Ten countries accounted for 75% of the global gap between treatment enrolments and the estimated number of new cases of MDR/RR-TB in 2018, and thus will have a strong influence on progress in closing this gap. Those 10 countries were China, India, Indonesia, Mozambique, Myanmar, Nigeria, Pakistan, the Philippines, the Russian Federation and Viet Nam. China and India alone accounted for 43% of the global gap. - Global Tuberculosis Report 2019
According to results from 2017 using the Oxford GBD’s results tool, South Asia is the region being hit hardest by drug-resistant tuberculosis, and it’s not even close. Where other regions are showing a downward trend in extensively drug-resistant TB deaths, South Asia is continuing to climb consistently. When it comes to MDR-TB, South Asia suffered an estimated 71,975 deaths. The next region after them is Eastern sub-Saharan Africa with an estimated 14,028 deaths.
“TB’s a tricky one,” surmises Haines-Woodhouse. “You have new infections, but also re-lapsing ones going on and on – so it’s not just about having a resistant infection, getting treated for it, and then it’s gone.”
Drug resistant malaria is also becoming a headache for Asia and Africa as the mapping provided by the aforementioned interactive malaria drug resistance map indicates. The pathogen P. falciparum was name checked specifically in the report on malaria at the GLASS 2020 report conference, stating “resistance in the Greater Mekong sub-region does pose a challenge”.
It is imperative to understand that this is not just limited to antibiotics and bacterial infections. Antimicrobial resistance is an encompassing term referring to pathogenic resistance to drugs detected in viral, parasitical, fungal and bacterial infections. HIV is an example of a viral infection. Malaria is an example of a parasitical infection. Candida species are an example of fungal infections. Candidiasis is a type of fungal infection caused by Candida, which is a yeast. Candidiasis is the scientific name for thrush. Whether it be a vaginal, oral, skin, ear or bloodstream infection, drug resistant Candida infections are reporting a 57% fatality rate and are starting to ramp up in the USA. Once again, bloodstream infections caused by untreatable, raging STI’s are becoming just one of the future ways of the world.
READ: Candida Auris (C. auris)
Perhaps the most terrifying part of this ordeal is the world can get this right, overcome the odds and work together in an attempt to preserve antimicrobials, and the fight may still be lost. As mentioned before, pathogens are living things – they are microorganisms, they can evolve, they will become resistant to whatever we use to treat them.
“The reason bacteria are so successful as a species is because they evolve very quickly. Bacteria are set up to duplicate very rapidly, and every time they duplicate there is a chance their genetics can change. It’s the same as evolution, only sped up by a few million years.” — GEORGINA HAINES-WOODHOUSE
The other aspect to this is that pathogens don’t just become resistant to one specific drug; they become resistant to the majority of the ‘class’ of antimicrobials. ‘Class’ refers to the way in which antimicrobials attack a pathogen. For example, penicillin is a class because it attacks or synthesises a bacterial infection’s cell wall. Within the class of penicillin, there are multiple variations. If a pathogen becomes resistant to one drug within the penicillin class, all other drugs within that class are highly likely to become redundant.
READ: Antibiotic Classification & Mechanism
“[Antibiotics are] not easy to find,” says Haines-Woodhouse. “For them to work they have to keep up with bacteria, and that’s no easy feat.”
The Antimicrobial Market
At face value, there seems to be an exceptionally easy and overtly obvious answer to all this, but it is an answer that is unsubstantiated: the commonly held belief that pharmaceutical companies should just create more classes of antimicrobials.
In the words of Anne-Maree Englund, Policy Manager and leader of the response to AMR at pharmaceutical company Merck, Sharp & Dohme Australia (MSD): “it’s the elephant in the room; the market for novel antibiotics is broken”.
Across all three interviews conducted for this piece, this sentiment was an explicitly common theme; and as things stand, it must be understood that it is bordering on corporate suicide for a pharmaceutical company to attempt to create a new, specifically targeted antibiotic.
“If I was a pharmaceutical company, why the fuck would I make antibiotics?” — DR CHRIS MOY
Here, the world encounters the crux of the conundrum that is AMR. The companies that the world needs to be manufacturing new drugs are not getting any reward or incentives for their efforts, yet are still expected to dive head first into the abyss of antimicrobial research and development.
But what do these ‘efforts’ entail? Estimates suggest that with no government incentives, it costs USD $1.6 billion to manufacture an antibiotic that will specifically target a resistant infection across a timespan of 12 years. According to Englund, pharmaceutical companies need a “profit of around $300 million per year” in order to maintain operations.
It equates to $133 million per year being spent on one project, meaning at the bare minimum $400 million of profits need to be made elsewhere. Even thinking about that many zeros is enough to make someone dizzy.
As we’ve discussed, bacteria are a ‘super-evolver’. If a company is spending 12 years on a targeted resistance, there is every chance the bacteria could evolve by then, making the new drug redundant and sending $1.6 billion and 12 years of valuable time down the toilet.
“There’s no incentive for pharmaceutical companies to make new antibiotics.” — GEORGINA HAINES-WOODHOUSE
But these are estimates, projections, hypotheses. The question is, do pharmaceuticals hit a financial wall in the face of the antimicrobial market? Yes.
Cited by Englund as a prime case study of the problem pharmaceuticals face, the last two years for Achaogen, a biopharmaceutical company based in California, make for damning reading.
READ: Achaogen Bankruptcy Raises Worry Over Antibiotic Pipeline
In 2018, Achaogen’s new drug ‘plazomicin’ was granted FDA approval. The antibiotic was considered a breakthrough for treating carbapenem-resistant Enterobacteriaceae - which is listed as a critical antimicrobial resistance in Australia’s CARAlert report. Enterobacteriaceae cause Shigella spp., E. coli, and Salmonella spp., which are all under severe scrutiny from GLASS and GRAM. Clearly, this drug is something the world desperately needs, and demand and profits would surely be soaring.
Achaogen filed for bankruptcy on April 15th, 2019.
It is emblematic of the issue that profits for antimicrobials are gained through volume sold. For a chronic illness this system works fine, but infections can be killed off and antimicrobials are sold for a shorter period of time. There is no incentive to continuously be making new ones, especially if they are not even going to be used as a primary option.
“Doctors like to keep them available as a backup option,” says Englund. “But they don’t want to use them.”
The issue here is government policy. Here in Australia, under the Pharmaceutical Benefits Scheme, the Government subsidises the cost of a list of medications that is frequently updated. For chronic illnesses, this works a treat and, for Australians with chronic illnesses, it is a good policy. However, antimicrobials are different as they are designed to kill off an infection over a designated period of time, and not meant to be used unnecessarily. This means smaller profits for fewer antimicrobials and a collection of the same drugs being used to treat the same, potentially resistant infections. There must be a new system created to pull pharmaceutical companies into the market for researching and developing new antimicrobials.
READ: Revised PBS Listings for Antibiotic Use
The other issue is finding a government that is willing to sacrifice concepts such as the global war economy and instead focus on spending elsewhere. For an example, the Australian Government just announced recently that they will be spending $270 billion on the defence budget. As Englund puts it: “every time I hear about submarines and fighter jets, I think we just need one of those to get some funding”.
“We need a new funding mechanism for novel antibiotics,” she concludes.
“Is it possible we should prepare for threats other than terrorists?” — AL GORE, AN INCONVENIENT TRUTH (2006)
One such system is entering its pilot phase in the United Kingdom. Scrapping the practice of paying pharmaceuticals for the volume of drugs sold, the Government announced last year in June the intention to provide a new ‘subscription’ style model where companies are paid upfront for access to antimicrobials based on their usefulness to the National Health Service (NHS). What this system does is encourages manufacturers, researchers and developers to invest the money required with the knowledge that, if they produce a targeted drug, their return on investment is immediate, does not depend on the volume of drugs sold, and doctors can keep new drugs in reserve without any external pressure.
READ: Development of New Antibiotics Encouraged with New Pharmaceutical Payment System
The system came into operation on the 17th of June this year. It is a system that every global government must be following closely; it provides a viable option for the future of antimicrobials, pharmaceutical companies, clinicians, patients and the government. If not, the consequences could be catastrophic.
“There is no greater threat to global health than drug-resistant infections, yet there have been no major new antibiotic drug classes discovered since the 1980s.” — UK HEALTH AND SOCIAL CARE SECRETARY MATT HANCOCK
In Conclusion
COVID-19 is not an example of antimicrobial resistance. It is a Severe Acute Respiratory Sickness (SARS) caused by a coronavirus and cannot be treated by antibiotics. However, the current situation the world is in provides an apt analogy for the world everyone will be living in if action is not taken.
Think about it; we are living in a world where an unknown disease is rife with no available or prospective cure. Healthcare systems are being overloaded and collapsing under the strain of demand. The more confined people are, the more they spread the disease. Even if they survive the disease, in some cases the quality of life people are experiencing is drastically reduced. People are being overloaded with medical bills due to long stays in hospital and the ICU. People are not able to go to work, and thus the economy is suffering. People are being told to stay home and save lives, but the longer people stay inside the more issues such as deteriorating mental health and domestic violence rise.
No matter which way one looks at it, there’s something in there for everyone to panic about. Whether someone’s main concern is global dominance, the climate, the economy, poverty, healthcare, their family, or just life in general – this will affect everyone. We are experiencing a mild taste of our possible future right now.
So, now are you thinking of a future with untreatable STIs and explosive diarrhoea, a future where a small cut could kill, a future where life-saving surgeries, joint-replacement operations and chemotherapy become too risky to undertake – a future where all modern medical methods are exceptionally high-risk and can no longer be performed?
To reiterate: there are pathways out of this upcoming crisis; a collaborative, globalist effort on behalf of all governments in transparency and reporting of data to surveillance systems, strict antimicrobial stewardship programs (both for humans and animals) and a reinvention of the antimicrobial market can all go a long way, but we need to start thinking and acting for this now.
Because the less we think about it now, the more this futuristic dystopia becomes our reality.
“It’s up there with climate change. It’s a doomsday scenario.” — ANNE-MAREE ENGLUND, POLICY MANAGER AND LEADING AMR RESPONDENT, MSD AUSTRALIA