Antimicrobial resistance (AMR) poses a serious threat to public health, growth and global economic stability. We affirm the need to explore in an inclusive manner to fight antimicrobial resistance by developing evidence-based ways to prevent and mitigate resistance, and unlock research and development into new and existing antimicrobials from a G20 value-added perspective, and call on the WHO, FAO, OIE and OECD to collectively report back in 2017 on options to address this including the economic aspects. In this context, we will promote prudent use of antibiotics and take into consideration huge challenges of affordability and access of antimicrobials and their impact on public health G20 Leaders Communique, Hangzhou Summit 4-5 September 2016, point 46
By Garance Fannie Upham
Chief Editor AMR-Times
AMR as a Key Issue for BRICS and Low-Middle Income Countries
1) The BRICS and LMI countries (Brazil, Thailand, etc.) have recently insisted in WHO fora that the issue of pharmaceutical resistance should not allow global health policy setting to forget ‘access’ because more people die yearly from lack of access to antibiotics than from resistance to medicines. Today this message has begun to be heard : United Nations Access campaign and other fora have revived a worldwide access to medicines campaign.
2) Resistance is a global phenomenon and low income countries and communities will have a harder time facing this problem, especially because of weak health care systems.
3) There is a tendency among doctors treating middle class patients in LMICs to prescribe latest antibiotics because they are informed about the ‘resistance’ issue, so they prescribe strong, last state of the art meds ‘just in case’, but in doing so, they fuel resistance in their own settings. The same error exists, of course, in well-to-do countries.
4) The lack of diagnostic tools, diagnostics laboratories and personnel, means that antibiotics are prescribed needlessly, for example, for children with diarrhea while most of it may be viral or parasitic in origin. And hospitals do not provide the full course of treatment (even when cheap generics are there), forcing poor parents unto the black market where substandard drugs may be offered.
5) To reduce demands on antibiotics in poor countries, the first, essential policy action would be to invest in safe potable water and sanitation. The London School of Economics did a remarkable study (The Impact of Water and Sanitation on Diarrheal Disease Burden and Over-Prescriptions of Antibiotics) on four countries : Brazil, India, Indonesia and Nigeria and their analysis was that close to 500 million cases of childhood diarrhea every year in these 4 countries would be prevented by implementation of WASH (Water- Sanitation- Hygiene), a study commissioned by the UK based Review on AMR (report number 6), March 2016.
6) There is an urgent unmet need for ‘Infection Prevention and Control’, ie patient safety and health care workers safety in health care systems. But no one is putting in the effort. Even in Ebola devastated countries, the funding went to Zika after the Ebola immediate crisis was over, leaving health structures as dirty as before and thus as dangerous in the time of AMR as could be. The WHO DG Dr Chan initiated safe injection campaign a couple of years ago, has been limited to pilots in 4 countries for lack of funding, leaving intact the estimated 6 billion estimated dirty injection practices per year in health care systems. The campaign for ‘Smart (Non-Reusable) Syringes’ will be relaunched at the May 10-12 WHO World Forum on Medical Devices, in Geneva this year.
7) The HIV AIDS epidemic has no end in sight (Cape Town AIDS conference outcome): yet PLWHIVAIDS will be the first affected by AMR, and are already the first to die from AMR because a) opportunistic infections may also be the drug-resistant type b) they will be more at risk from contracting a drug-resistant infection in health care because they will be more frequently in these, c) they are at risk from antiretroviral-resistant HIV (both acquired or health system transmitted). See Nigel Livesley, ASSIST USAID program in AMR Control 2016.
8) The tuberculosis epidemic is wide and continuing and latest estimates of drug resistant TB in India are that real figures are 2 to 3 times higher than reported up to now. (The Lancet, Aug 24th 2016, estimates from drug sales). Yet TB, from India to Eastern Europe, or Greece, is intimately linked with poverty, overcrowded slums, poor nutrition, or helminthic parasitic pollution of the water supply (study in South African slums). Besides better point of care diagnosis for TB and TB drug susceptibility, there is an urgent need for better housing, nutrition, better working conditions for the poor of the world, as well as for the jail inmates. Let us not forget that HIV fuels tuberculosis and that tuberculosis fuels HIV in turn (NIAID 1996)
9) The dumping of untreated waste from antibiotic manufacturing in emerging countries (where most of worldwide medicine production is based) as well as a number of wealthier countries, combined with the dumping of waste from meat and fish industries (both antibiotics residues and meat waste with bacteria resistant to antibiotics) into rivers and soil is a global problem. There is an urgent need for State regulations to forbid this dumping as it is one of the main source for the creation of bacterial genes resistant to antibiotics which have demonstrated the capacity for worldwide travel. There is an urgent need to demand and impose that corporations and manufacturers, as well as hospital structures, use proper technologies to treat their waste and not release them in the environment. Some industries have called for responsibility in this regard (DSM Sinochem). There is an urgent need for cleaner practices and more respect for meat industry workforce as indicated in the new book “Chickenizing”, a first history of food production.
10) While the need for new antibiotics is very real, does it mean that reward for R&D should be equal to the one billion dollar expected income from sales of just one anti-cancer drug or one anti-HIV drug? There is an urgent need to think through a public inter-governmental system to reward public or private innovation in antibiotics with an adequate Prize system. There is also the need to examine the potential of plants (90% of plants used in traditional medicines have not been researched, says Cassandra Quave, Emory University in AMR Control 2016), as well as to invest into R&D in other avenues such as the use of phages (viruses which exist in nature, specific to bacterias). The Pasteur Institute is organizing a Phage day on April 27, 2017.
In the face of this there is, unfortunately, a tendency to ask for extended or even ‘lifelong’ patents, and prices to be multiplied a 10 to 100 fold or more.
Too many global programs on AMR (most of them, in fact) start with behavior modification:
– patients called ‘users’ should behave better and not ask for antibiotics from prescribers, and should take their prescription to the end (the later recommendation has no scientific basis, except for special long term treatment diseases like tuberculosis);
– doctors should behave better (and prescribe less);
– hospitals should prescribe less (while sometimes their income is related to their sales of meds!),
– veterinarians should prescribe less (but there too, their income may be tied to their sales),
Perhaps, indeed, all true (or most of it).
Yet, the underlying hypothesis is that of the economic ‘free agent’ in the ‘free market’- whereas the response ought to be from the standpoint of public interest and public health.
Doctors must also have a certain degree of freedom and guidelines not put people with co-infections at risk. We need fundamental research on co-infections and take it into consideration in programs (helminths and TB, helminths and HIV, measles and bacteria, etc.)
There is a need to STOP BLAMING THE VICTIM and take public health responsible action.
In the face of AMR the need is for PUBLIC INTEREST INVESTMENTS and orientation: clean environment, access to clean water, stronger and much cleaner health systems, regulations for public health, and stronger investments in public universities basic research.
At the same time, and contrary to the ‘evidence-based’ quick fix and solutions, the issue of AMR poses a challenge to the health system as a whole.
There is an urgent need to develop a ‘patient based system’, which does not mean one where the patient is treated as a mythical ‘free consumer’ but, rather, a 21rst century science based health system which goes to the patient instead of demanding that the patient travel to treatment in LMICs. With internet, video capsules in gastroenterology, ambulatory surgery, diagnostic at the point-of-care and from a distance, clean water generation, solar and other electricity producing innovations, we could envision a very modern form of primary and secondary health care:
AMR poses that global challenge: implementing the Right to Health for All.