On June 6, ReAct-Action on Antibiotic Resistance in collaboration with the Every Woman Every Child initiative within the office of the United Nations (UN) Secretary-General and the Dag Hammarskjold Foundation hosted a briefing on “Meeting the Multisectoral Challenge of Antimicrobial Resistance”. The briefing aimed to raise the issue of antimicrobial resistance or AMR to the top of the political and global agenda in anticipation of a high-level meeting on this issue during the UN General Assembly in September.
The speakers and participants spoke of the impact of antimicrobial resistance (AMR) across sectors including human health, agriculture, and the environment. This event, co-sponsored by the country missions of Sweden, Netherlands, South Africa, Vietnam, Mexico, Argentina, and South Korea, brought together a broad range of stakeholders from high-level government representatives and intergovernmental organizations to private sector and civil society representatives in human and animal health.
Global coordination to address AMR needed
The urgency for global coordination to address this growing threat across sectors has never been greater. Evidence continues to mount of resistance to colistin, a last-line antibiotic in human medicine across countries in Africa, Asia, Europe, and the Americas, linked to its use in food animal production. At the same time, providers, patients, and producers continue to face a dearth of new antimicrobials in the R&D pipeline further limiting options for treatment of both humans and animals as resistance spreads. Access to effective antimicrobials also continues to a barrier for patients, particularly in low- and middle-income countries. As Nano Kuo, Manager of Every Woman Every Child, stated in her opening remarks, “Simply put, antimicrobial resistance is one of the most significant global challenges we face today…We will need to galvanize action from across sectors and multi-stakeholders, from the public and private sectors, scientists, doctors, patients and consumers themselves and across the multilateral system. It is clear AMR is not an issue that can be dealt with in isolation.”
AMR would jeopardize “the call to action of the UN Secretary General – to end preventable deaths of women, child, and adolescents in a generation.”
Through a video message, Ambassador Juan Jose Gomez Camacho, Permanent Representative of Mexico to the United Nations and chair of the upcoming High-Level Meeting on AMR, reaffirmed Ms. Kuo’s remarks in that AMR would jeopardize “the call to action of the UN Secretary General – to end preventable deaths of women, child, and adolescents in a generation.” He expressed confidence that briefing discussions would point towards potential recommendations to reverse AMR across sectors that would lend valuable input towards preparations for the high-level meeting in September. Lord Jim O’Neill, Commercial Secretary to the Treasury and Chairman of the United Kingdom Review on AMR (UK Review on AMR), then took the floor to give an overview of the 10 recommendations detailed in the their final report, released in May 2016.
These recommendations, spanning across human and animal health, call on Member States as well as other stakeholders including intergovernmental agencies, industry, and civil society to play a part. This rich set of proposals includes:
- a Global Innovation Fund for Early Stage and Non-Commercial R&D
- late stage market entry rewards of $1 billion USD per drug
- a “pay or play” proposal for the pharmaceutical industry
- top-up payments for diagnostics for low- and middle-income countries
- targets to lower antimicrobial use in agriculture over 10 years
- restrictions on critically-important antimicrobials in food animal production
- improved transparency of antimicrobial use in the food industry
- a global surveillance network for monitoring antimicrobial resistance in food animal
- increased use of vaccines and other alternatives in food animals and
- a strengthened veterinary workforce — so critical to effectively manage the use of these drugs in food animal production.
Panel discussion – participants from government, academia to civil society
Dr. Anthony So, director of the Johns Hopkins Center for a Livable Future and ReAct North America, then opened the panel session of the briefing, which included leading figures across both human and animal health from governments, academia, and civil society. Starting with a discussion on the impact of AMR on human health, he introduced two leading figures in the access to medicines movement — Director-General Precious Matsoso for the National Department of Health for South Africa and Mr. Rohit Malpani, Director of Policy and Analysis for the Médecins Sans Frontières’ (MSF) Access Campaign. Director-General Matsoso, who also serves on the UN Secretary-General’s High-Level Panel on Access to Medicines, highlighted the challenges of ensuring access, not excess, to effective antimicrobials, in terms of availability and affordability. Both she and Mr. Malpani, also called for coordination between the different global policy processes and proposals on innovation including the UN High-Level Panel on Access to Medicines and the World Health Organization (WHO) Consultative Expert Working Group on Financing R&D.
Mr. Malpani outlined some limitations to UK Review on AMR’s recommendations in ensuring affordable access. These include not always fully supporting delinkage and limiting the principle to stewardship, particular diseases, or only low- and middle-income countries; calling for advance market commitments for diagnostics and vaccines that may not safeguard sustainable access; and recommending billion dollar incentives geared towards towards pharmaceutical companies without assurances of affordability. He also highlighted the importance of ensuring access to vaccines, such as the pneumococcal vaccine where universal coverage is estimated to result in a 47 percent reduction in antibiotic use for those with the pneumococcal infection. Both Mr. Malpani and Director-General Matsoso also urged country governments and the WHO to take a leadership role to set priorities for R&D framework to address AMR “that puts patients’ needs first”.
Case studies from countries
Transitioning to second half of the panel with speakers offering a perspective from civil society and case studies from a high and low-and middle income countries in curbing AMR in food animal production, Dr. So began by acknowledging that these drugs have a dual market in both humans and animals. He noted that uses of critically important antimicrobials for non-therapeutic indications including for growth promotion, for prophylaxis, or for offsetting poor hygienic conditions “risk squandering these precious resources”.
The next panel speaker, Mr. Steven Roach, Food Safety Program Director for Food Animals Concerns Trust and Senior Advisor to the Keep Antibiotics Working Coalition pointed out that the emergence of colistin resistance falls into a well-known pattern of growing resistance to other medically-important antimicrobials due to their use in food animal production. He agreed with the UK Review on AMR’s recommendation for setting targets for antimicrobial use, but added that it must be done so cautiously so that “reductions do not cause disparate impacts and harm small producers or create unfair advantages for some countries.” Mr. Roach also called for international consensus in banning the use of such critically-important drugs like colistin.
The next two panelists than offered lessons from their countries in monitoring and reducing antimicrobial use in livestock and aquaculture. First, Dr. Jaap Wagenaar, Professor of Clinical Infectiology of Utrecht University, spoke of the Dutch experience in lowering antimicrobial use in agriculture by 70 percent in the Netherlands, the second largest exporter of agricultural products in the world. Key elements of their successful policy included setting specific reduction targets, mandating transparency of use through registration of farms in centralized databases to enable surveillance, and benchmarking and defining antimicrobial use targets across sectors by the independent Veterinary Medicines Authority. In 2011, the government placed a ban on prophylactic use of antimicrobials and required that these drugs be exclusively administered by veterinarians, unless the farm was able to comply with strict conditions.
Perspective from South Korea
Offering a perspective from an earlier low- income country country, Dr. Yong-Sang Kim, Director of Animal Health Management Division for the Ministry of Agriculture, Food and Rural Affairs, outlined the South Korean government’s’ efforts to curb antimicrobial use. Following national uproar due to a published survey by a local consumer advocacy organization of high levels of resistance to antimicrobials in livestock and fish products linked to the inappropriate use of these drugs, the government issued a series of regulations over 10-year period to address antimicrobial resistance. These included banning antimicrobials in a stepwise manner in feed, mandating veterinary oversight to administer these drugs, and strengthening national surveillance. To address staunch opposition from the farming sector due to concerns around increased production costs and increased incidence of disease, the government provided financial support to encourage good animal husbandry practices to offset the use of these drugs. Also contributing to the success of these efforts, the government also garnered strong support from local consumer advocacy organizations highlighting the need for broad stakeholder engagement to address this complex issue.
WHO Assistant Director-General
Following this truly multisectoral set of speakers, Dr. Anthony So invited discussants Dame Sally Davies, Chief Medical Officer for the United Kingdom and Dr. Keiji Fukuda, WHO Assistant Director-General and Special Representative on AMR, to offer their reflections. Dame Davies stressed that the upcoming High-Level Meeting on AMR would only be as powerful as Member States and other stakeholders in the room wish it to be, adding:
“[let’s] not let AMR be the reason that the Sustainable Development Goals don’t deliver.”
Dr. Fukuda called for broad stakeholder engagement in the UN process and the opportunity for leadership among Member States on this issue.
Participants at the briefing were then invited to deliver interventions from the floor. Remarks were given by a broad range of stakeholders including from country mission representatives, intergovernmental agencies, civil society, and the private sector. Ms. Carla Mucavi, Director of the Liaison Office to the UN Food and Agriculture Organization spoke of the burden of AMR mostly affecting those rural poor who live in close contact in animals and poor sanitary conditions. She noted that smallholder farmers are typically women, who are exposed to resistant pathogens for which there is no medicines available. She iterated FAO’s commitment to the One Health approach with WHO and OIE to combat AMR in agriculture and aquaculture.
Sustainable manufacturing practices
Mr. Lucas Wiarda, Global Marketing Director and Head of the Sustainable Antibiotics Program of DSM Sinochem also voiced his company’s commitment to adopt more sustainable manufacturing practices to prevent antimicrobial pollution that contributes further to resistance. He called for leadership from policymakers to set regulations on these practices as well as industry to adopt better manufacturing practices. Ms. Jean Halloran, Director of Food Safety at Consumer Reports, expressed her frustration around the lack of action despite recognition of the issue across sectors. Besides calling for hospitals to make public their infection rates, she noted that the experience of the Netherlands is particularly instructive in that antimicrobial use in food animals is needed at the level of facilities, farms, and plants. She concluded by saying that she felt encouraged by the briefing discussions and the global mobilization that would occur in September at the UN High-Level Meeting on AMR. Dr. Otto Cars, founder of ReAct-Action on Antibiotic Resistance also raised concerns that the incentives being discussed were too focused downstream instead of where the true scientific bottleneck lies upstream in antimicrobial drug development.
Panelists were also invited to give final reflections. Of note, Mr. Roach of Food Animals Concerns Trust pointed to the ongoing efforts of consumer advocacy organizations in moving the food industry to source meat products raised without the routine use of antimicrobials, thereby shifting the market demand. While such efforts have been successful in the United States, these practices have not been adopted globally for these same retailers with large franchises abroad. Funds for global awareness campaigns as has been proposed by the UK Review on AMR might be more strategic if allocated to these consumer advocacy organizations already engaged in such efforts.
In closing this panel, Dr. So pointed again to the need for global coordination across sectors to effectively address AMR. He noted that:
Tackling antibiotic resistance will take:
More than just drugs—we’ll need diagnostics and vaccines as well;
More than focusing incentives on one company, one drug at a time—we need financing that will transform how we innovate, delink return on investment from volume-based revenues, offer a portfolio of promising products, and rethink how we deliver these health technologies to those in need;
More than just the efforts of the Health Ministry—we’ll need a whole-of-government commitment;
More than just the efforts of health care providers and patients—we’ll need our agricultural sector to do its part in curbing non-therapeutic use of antimicrobials. A One Health approach.
And more than just those of us who have worked tirelessly on this issue for years—we’ll need all of you.
He then invited Nana Kuo to facilitate the closing remarks from H.E. Gabriel Wikstrom, Minister for Public Health, Healthcare, and Sports of Sweden and Ambassador Mateo Estrémé, Deputy Permanent Representative of Argentina to the United Nations. They both reaffirmed the need for collective action from all stakeholders through the UN, but also tailor-made approaches so that addressing AMR across countries can be realized.
Resource Materials on AMR (distributed at UN briefing)
Curbing Antimicrobial Resistance in Food Animal Production – ReAct-Action on Antibiotic Resistance and Johns Hopkins Center for a Livable Future
Antimicrobial Resistance: A Threat to the World’s Development Agenda (Dag Hammarskjöld Foundation’s Development Dialogue Series) – ReAct-Action on Antibiotic Resistance
A Framework for Costing the Lowering of Antimicrobial Use in Food Animal Production (Commissioned Paper for the UK Review on AMR) – ReAct-Action on Antibiotic Resistance and Johns Hopkins Center for a Livable Future