Antimicrobial resistance (AMR) is a serious problem. In 2014, the Prime Minister described it as having the potential to cast us back “into the dark ages of medicine”. This month, the Government added AMR to the National Risk Register of Civil Emergencies, threatening that around 80,000 people could die if there was a widespread outbreak of a resistant microbe. Thankfully, the first quarter of 2015 has seen a series of announcements pledging money and resources to fight the global health security risk posed by AMR. The Society’s Policy Officer, Dr Paul Richards, has broken down who announced what and when.
Hidden away in the UK 2015 Budget was the Government’s announcement of a £195 million ‘Fleming Fund’ that will see them working with the Wellcome Trust and other global organisations to improve surveillance networks in low- and middle-income countries. Although the details of the fund are yet to be announced, this figure represents a substantial sum, particularly given that the Medical Research Council have estimated that the UK’s spending on AMR research between 2007 and 2014 totalled £275 million.
The UK research councils have already committed £28.5 million to support AMR research, while the Government’s current initiatives, which include AMR surveillance, infection control and prescribing practices, were described in the UK 5 Year AMR Action Plan. It’s not just the UK committing funds; in January, it was announced that President Obama’s 2016 Budget proposal would seek to double the US Federal Government’s investment on tackling AMR to nearly $1.2 billion.
In February, the European Commission’s ‘Horizon 2020’ funding programme opened calls for the €1 million ‘Horizon Prize for Better Use of Antibiotics’, which has set the challenge of developing a cheap and easy-to-use diagnostic test to distinguish between upper respiratory-tract infections that require antibiotics and those that do not. Similarly, the Longitude Prize was launched in 2014, with a £10 million prize pot available to those developing a point-of-care diagnostic tool that can differentiate between bacterial and viral infections.
Direct funding is not the only way that money is being used to fight AMR: economics are also being used to incentivise both policy makers and businesses to take action. Most recent policy reports or news stories are set against a backdrop of the societal and economic costs of inaction.
It is not surprising then that last July, the UK Prime Minister commissioned renowned economist Jim O’Neill – rather than an eminent policy professional or academic – to chair an independent Review on Antimicrobial Resistance. The review is strongly focused on addressing the international economic issues surrounding AMR, such as the costs of inaction and the funding and market incentives needed to jump-start action from academia and industry.
While emphasising the health security threat posed by AMR, the Prime Minister’s announcement of the review noted that Britain could lead the way in antimicrobial development with its “world-class pharmaceutical sector – which employs thousands of highly-skilled experts and is a key part of the country’s economy”. It appears that economic gain from potential growth in AMR has acted as an additional incentive for the Government to engage with this issue.
The Review’s first report, published in December 2014, employed economic modelling to highlight AMR as a “crisis for the future health and wealth of nations”. Focusing on just six of the most common resistant infections, the report estimated that by 2050 AMR could account for 10 million extra deaths per year, and could lead to a cumulative cost of $100 trillion through lost productivity and increased health care costs. Those headline figures certainly grabbed the attention of international media.
January saw the publication of the Review’s second report, which detailed under-investment in financial and human capital as a key barrier to tackling AMR. For example, the report highlighted that between 2010 and 2014, US National Institute for Health spending on AMR was $1.7 billion, over 15 and a half times less than that spent on cancer over the same period. The report highlighted such funding disparities as a barrier to scientists and clinicians entering and sustaining a career working on AMR and infectious diseases, and urged international investment in this area. Another headline recommendation was the establishment of an international ‘blue sky’ innovation fund to tackle under-investment in the fundamental and mid-stage research that is needed to drive the development of new antimicrobials and diagnostics.
It is welcome to see high-profile flagging of the need for a strong academic, public health and small industry research base if we are to tackle AMR. Indeed, when the Review surveyed companies and organisations involved in antimicrobial development, early stage grant funding ranked slightly higher than higher market prices as the top solution that would likely lead to better research outcomes. The need for a strong AMR research community is certainly something the Society for General Microbiology recognises and is something we are working with other learned societies to support.
Launching the Review on AMR last July, the UK Prime Minister said, “There is a market failure; the pharmaceutical industry hasn’t been developing new classes of antibiotics, so we need to create incentives”. It is clear that this is the case based on the Review’s survey of companies and organisations involved in antimicrobial development, which found that 80% of 40 companies who responded rated economics as the biggest barrier to investment; this is despite 70% of those respondents who had invested in antibiotics in the 1990s having made a profit.
The problems with the antimicrobials market were neatly summed up at the Chatham House debate I attended in February. Dr Nick Cammack, GlaxoSmithKline’s Senior Vice-President and Head of Medicines Development for Diseases of the Developing World, noted that, confusingly, disinterest in the antimicrobial market arose in part due to its very success, as competition and market fragmentation resulted in less returns on investments. Dr Cammack also emphasised the unique scientific challenges associated with antimicrobial development, which lead to an extremely protracted development pipeline. Professor Kevin Outterson, from the Centre of Global Health Security, highlighted the paradoxical problem policy makers face in that they need to bring about reductions in antimicrobial use, while at the same time incentivising pharmaceutical companies to enter what will be a shrinking market. It will be interesting to see how O’Neill’s Review on AMR tackles this challenge in its next report, which will outline actions to incentivise the antimicrobials market.
It is worth noting, however, that the rise of AMR on the policy agenda could act as an incentive in itself. Pharmaceutical giant Merck completed its $9.5 billion acquisition of Cubist in January, which was driven by interest in Cubist’s antibiotics portfolio. Could we be on a cusp of an antimicrobials ‘gold rush’?
We live in an increasingly globalised world and AMR certainly does not respect international borders, so any hope of stemming its rise depends on a coordinated international response. The UK and Swedish governments were instrumental in pushing for the development of a WHO global action plan on AMR last year, which has been drafted and will be submitted to the World Health Assembly in May.
Although world leaders will hopefully adopt the action plan, the big question remains: ‘who will pay?’ Speaking at the Chatham House event, both Dr Manica Balasegaram from Médecins Sans Frontières and Dame Sally Davies, the UK Chief Medical Officer, noted the recent response to Ebola and highlighted that international funding to support the WHO is often not forthcoming.
While high-income countries are well placed to tackle AMR, they will need to provide additional sustainable infrastructure and capital – above what they have already dedicated nationally. Many low- and middle-income countries lack the health infrastructures to fund and support basic infection control, let alone public AMR surveillance and education programmes. The announcement of the UK Government’s Fleming Fund is welcome in this respect, but is likely only a small proportion of the financial support that will be required for an effective global response. It will also be interesting to see if the international community heeds the recommendations being made by the O’Neill Review on AMR to improve the research base and incentivise the antimicrobials market.
The Society for General Microbiology recently launched the Small World Initiative, which will get school pupils, university students and the public involved in sampling soil for antimicrobials. We hope to at least highlight the challenges faced by both researchers and pharmaceutical companies in developing viable antibiotics.