How To Prevent Millions of Deaths from Failing Antibiotics

One death every three seconds, all around the world.

That will be the toll of antibiotic resistance by the year 2050 if nations don’t take sharp, immediate action together to prevent it. But prevention is possible, a report issued Wednesday argues—and it makes a slew of specific (and possibly controversial) prescriptions.

Those include requiring doctors to check patients with a rapid diagnostic device before writing prescriptions; compelling drug companies to underwrite the development of new antibiotics, even if they don’t themselves make them; asking governments to set explicit 10-year targets for reducing antibiotic use in agriculture; and creating a global watchdog body—potentially separate from existing ones such as the World Health Organization—to ensure progress is made.

The report is the final document issued by the Review on Antimicrobial Resistance, a project chartered in 2014 by UK Prime Minister David Cameron, backed by the powerful charity the Wellcome Trust, and headed by Lord Jim O’Neill, the former chief economist of Goldman Sachs, who is now a minister in Cameron’s government.

Since December 2014, the small group has issued eight reports examining what contributes to the rise of resistance, which has undermined the action of almost all the antibiotics used in the world, and exploring what could be done to stop it. The final report sums up the work and explains how different sectors of global society—not just medicine, but business, finance, politics and agriculture—will have to collaborate to avert a dire future.

How dire? The Review’s forecast of the potential cost of resistance, made in its first report, may be what it is best known for. It estimated that the global toll of resistance right now is more than 700,000 deaths per year—but it also predicted that if resistance is not reversed or slowed, the toll in 2050 will be 10 million deaths per year, along with a loss to global gross domestic product of $100 trillion.

“It is fair to assume that over 1 million people will have died from (antimicrobial resistance) since I started this Review in the summer of 2014,” O’Neill writes in the new report’s foreword. “This is truly shocking.” And, the report adds, the 2050 prediction may be an underestimate, because the calculation does not account for procedures—such as hip replacements or Caesarean sections—that would be made more hazardous by resistant infections but might not result in deaths.

Tackling antimicrobial resistance is absolutely essential. It needs to be seen as the economic and security threat that it is. – Lord Jim O’Neill

O’Neill is not a medical scientist and was best-known before the Review started for coining the concept of the BRICs, which stands for “Brazil, Russia, India, China” but encapsulates a prediction that the rise of those secondary economies will create an earnings powerhouse that surpasses the industrial West. So the Review’s final proposals are not exclusively medical, but instead aim to change behavior—of individuals, and institutions and companies—by creating incentives and putting up subtle roadblocks.

It estimates that following the proposals could cost $40 billion over 10 years.

“My belief is that we have come up with pretty implementable solutions,” O’Neill told me in a phone call. “What they really require is for key participants to just behave a bit differently than how they have. To some degree it is a change of mindset, and that is more important and bigger than the money. Forty billion dollars obviously is an enormous amount of money, but that is one-quarter of one-tenth of one percent of global GDP. It should be regarded as a very cheap investment, not a cost.”

(For context, the United States appropriated more than $5 billion to fight Ebola, which caused four cases of illness within the U.S. The Centers for Disease Control and Prevention estimates that antibiotic resistance affects more than 2 million Americans and kills 23,000 each year. The report notes: “The costs that we present here for mounting an effective pre-emptive response to it are substantially lower than the expense of responding once it becomes a true public health emergency.”)

The 80-page report contains 10 major proposals, split between reducing demand for antibiotics, increasing the supply of new drugs, and gathering political support to make change happen:

Create a “massive global public awareness campaign” that contains messages aimed at patients and doctors, and consumers and food producers, shaped around a core set of messages but tuned to the specifics of different cultures.

Improve hygiene, both in healthcare and in municipal sanitation, not only to reduce the spread of resistant bugs but also to prevent outbreaks—such as diarrheal disease in the developing world—that cause antibiotics to be overused.

Cut way back on antibiotic use in agriculture, by setting national targets, but also by enacting global bans on farm use of the last-ditch drugs that are “highly critical” to preserve for human medicine; and allow consumers a window into the system by including antibiotic use in all food labelling.

Create local and global surveillance systems that keep track of the emergence and movement of resistant organisms, and solve the data-ownership claims so that big data can be shared across borders.

Encourage the development of rapid diagnostic devices that can identify disease organisms and the drugs they are sensitive to, in hours instead of days, and insist on their use in everyday medicine so that antibiotics are not used when they are not needed. O’Neill writes in his foreword: “I find it incredible that doctors must still prescribe antibiotics based only on their immediate assessment of a patient’s symptoms, just like they used to when antibiotics first entered common use in the 1950s. When a test is used to confirm the diagnosis, it is often based on a slow technology that hasn’t changed significantly since the 1860s.”

Use more vaccines, in both humans and animals, to prevent the infections that antibiotics are otherwise used to cure. The report predicts that universal use of pneumococcal vaccine in kids could cut antibiotic prescriptions for pneumonia by almost half.

Boost the infectious-disease workforce—physicians, but also nurses, pharmacists and bench and behavior researchers—because the relatively low pay and prestige of that specialty compared to others is holding the field back. In the United States, infectious disease physicians earn less than those in 23 other specialties, and the National Institutes of Health sends just 1.2 percent of its grant funding to resistance projects, compared to 18.6 percent for cancer.

Launch a $2 billion “global innovation fund” to support early-stage research into new antibiotics as well as projects that would be difficult to commercialize. O’Neill said the United Kingdom and China have stepped up to be early investors, contributing $145 million, while the United States has created a federal “biopharmaceutical accelerator” to partner with private companies and nonprofits.

Overhaul the ways that drug development is funded. The report proposes a system of “market entry rewards” that identifies the drugs that are most needed and rewards developers with substantial payments when they bring the to market, so that their research and development costs and earnings expectations are reimbursed—and their need to press for big sales, which increase use and therefore resistance, is short-circuited.

Build a global political coalition that will press for action on resistance, and a “supra-national entity” that will monitor disease emergencies and policy attempts. O’Neill will present the Review’s proposals next week to the World Health Assembly, the annual meeting of the countries that make up the World Health Organization, and later this year to the United Nations. In addition, he said, China has assumed the presidency of the Group of 20, the global coalition of both industrialized and emerging economies, and will host the G20 Summit in September.

Gaining G20 backing is “if not the single biggest, the one of the biggest challenges” to creating resistance strategies that work, O’Neill said by phone, adding that some proposals in the report—such as setting national targets for farm antibiotic use instead of creating blanket bans—were phrased with developing economies in mind.

As the Review has been reporting, initiatives against antibiotic resistance have launched in several countries—not only the China-UK innovation fund, but the U.S. National Strategy against resistance, the U.K.’s  new $375 million Fleming Fund to support surveillance, and the World health Organization’s establishment of a Global AMR Surveillance System, known as GLASS. O’Neill said by phone that those moves spur hope that international agreement might be possible. “I am reasonably encouraged,” he said. ” I wouldn’t have done this if I thought it would be just a big piece of paper that sat on a shelf and gathered dust.”

Previous posts in this series:

• March 22, 2016: “To Slow Down Antibiotic Resistance, Focus on the Basics“
• Feb. 10, 2016: “As Antibiotics Fail, We Need More Vaccines“
• Jan. 20, 2016: “Pharma Industry Calls on Governments to Fund New Antibiotics“
• Dec. 7, 2015: “Proposal: Set International Targets for Farm Antibiotic Use“
• Sept. 9, 2015: “Can Offering a $12 Million Prize Make a Difference to Drug Resistance?“
• May 23, 2015: “We Need Antibiotics. They’re Not Profitable to Make. Who Pays?“
• Feb. 5, 2015: “How to Fight Superbugs: Start Spending Money“
• Dec. 15, 2014: “The Coming Cost of Superbugs: 10 Million Deaths Per Year“