It is abundantly clear that action in one country, whether it’s the UK thanks to the efforts of Professor Dame Sally Davies and Lord Jim O’Neill, or the great progress made in the Netherlands and Sweden, will be quickly undermined if all our neighbours don’t take similar preventative action. The European Commission has long been overly cautious in legislating to protect health, and has a sad history of only acting once faced with a full-blown crisis, like the BSE outbreak. That must not happen with AMR. The EU will publish a new multi-year action plan to support national governments next year, and it must step up to the scale and urgency of the AMR crisis. EU action on AMR should be guided by a “Health in All Policies” approach where health concerns are mainstreamed into other policies – in this case it must include stricter controls of antibiotic over-use in livestock and environmental standards to stop dumping of active antibiotic waste by pharmaceutical factories, wherever they are in the world. The complexity and multidimensionality of AMR means that successful action depends on many actions in various sectors, guided by the One Health approach.

AMR is one of the greatest negative side effects of the globalisation of trade

The potential scale of the threat - the O’Neill Review predicts 10 million deaths globally by 2050 if no action is taken, coupled with economic losses in their billions – and the fact that AMR cuts across national boundaries calls for urgent and determined EU action in this area. It is important to close the gaps between countries within the EU (both regarding antibiotics consumption and AMR prevalence), and on the other hand it is key for Europe to assert its position as a leading region so that best practices can also be shared and adapted to the needs to other parts of the world.

 

Environmental dimension of AMR

 

The environmental dimension of AMR provides an illustrative example of AMR’s intricacy, since it is not purely an “environmental” problem when antibiotics factories in countries like India or China pollute local ecosystems – rivers, soil, groundwater, etc. - with their manufacturing discharges. Firstly, the environment plays a key role as a vector of transmission; secondly, it functions itself as a reservoir for resistance development. As people (locals and tourists) and animals come into contact with resistant bacteria, the global mechanisms of mobility, trade and food chains ensure that drug-resistant bacteria can travel very quickly to Europe. What started out as an environmental issue thus turns into a healthcare issue as resistant bacteria are “received” by our hospitals and challenge public health. It is thus crucial to take a lifecycle approach to antimicrobials: care must be taken from production to their use in various settings to disposal.

In the end it is patients who will bear the consequences of AMR, regardless of its source – once multi-drug resistant ‘superbugs’ have entered the healthcare system, they are difficult to combat, even in countries where standards of infection prevention and control are very high. As Dame Sally Davies and others have warned, the “post-antibiotic era” could mean the end of modern medicine as we know it, given that both routine and specialist operations and procedures, from childbirth to organ transplants and chemotherapy, would become life-threatening endeavours if no effective antibiotics are at hand anymore.

The potential effects of AMR are so huge that they threaten the sustainability of health systems and call into question the attainment of the Sustainable Development Goals

Therefore, it is important to deal with the environmental impact of waste generated during the manufacturing process in a more proactive way, and to ensure that it is adequately addressed in the EU’s follow-up Action Plan on AMR, scheduled to be released during the first semester of 2017.  Alongside efforts to curb antibiotic consumption and promote prudent use in human health and agriculture, the root causes of the environmental dimension must be tackled.  Avoiding pollution arising from the antibiotics manufacturing process is a relatively easy fix, and it is a chance for the multi-billion euro pharmaceutical industry to demonstrate its declared commitment and responsibility by changing how it produces and sources its antibiotics, and ensuring full transparency of global supply chains.

While EPHA appreciates the industry declarations made at Davos and at the United Nations General Assembly, and also welcomes initiatives such as the Eco-Pharmaco-Stewardship (EPS) framework, we think that industry can and must do more to put its house in order. We think that this should be done without requesting vast amounts of public money: after all, AMR also threatens drug manufacturers’ own survival since their own products would be rendered worthless if they become ineffective. It is instructive to note that whilst many pharmaceutical companies have signed up to the Davos Declaration, many of the worst offending companies, including those further up the supply chain who work with some big name brands, are conspicuous in their absence.[1] This tells us that only a binding legislative approach will work, otherwise some unscrupulous companies will always be incentivised to cut corners.

Regulators should also play their part, beginning with the inclusion of environmental criteria into Good Manufacturing Practice (GMP), as advocated by the Swedish government. These must also apply to factories located in the developing world to avoid that major European and US companies take shortcuts by working with suppliers who circumvent the rules.

About EPHA’s AMR campaign

The European Public Health Alliance (EPHA) is the largest European public health platform whose members include disease-specific interests and patients groups, health professionals, vulnerable groups, researchers and regional interests. Antimicrobial resistance (AMR) is a key campaign topic for our members given that it is one of the biggest threats to health in Europe and globally, on a par with climate change. EPHA strongly advocates that AMR must remain high on the EU, national and international policy agenda, framed as a public health issue. Many actors, including policymakers, the pharmaceutical industry, farmers, veterinarians, health professionals and patients, play an important role in order to tackle it.