Sally Davies: the antibiotic resistance crisis

Chris - How do you pick your priorities though? When you are someone like the Chief Medical Officer, how do you decide what we are going to go after drinking, we're going to go after smoking? Is it just that you look at the statistics and you say, 'well, this is killing lots of people, this is putting lots of people in hospital, this is a problem, this is what we need to go for.' Or do you have a particular formula, or is it a pet passion? You think, 'well, I've wanted to sort this one out. That's going to be what I'm gonna make my mission as CMO.'

Sally - I think for some people it is their passion. My predecessor did wonderful work on patient safety and that had been a passion for him. For me, some things came round. The then Prime Minister David Cameron was asked in parliament for safe alcohol guidelines. So he said, 'yes, I'll tell the CMO to do them.' So I had to do them. Physical activity guidelines. No one had done them when I arrived and we just felt that we needed to give some guidance. The one which became very much mine and came out of the blue was antimicrobial resistance. So these are superbugs. It's when we misuse or actually use antibiotics properly. Actually, you can probably explain this better than me, <laugh> though I've been at this for years. The bacteria developed resistance in order to stay alive. And then of course people die of these resistant bugs. A lot of people think it's the person who's resistant. It's the bugs that are resistant. And I did with my first  Chief Medical Officer annual report, realised that not only was antibiotic resistance and other bugs resistance going up and up and killing more people, but that we had an empty pipeline of drugs. So there wasn't a solution coming. And I've been working on it ever since, even since I stopped being CMO.

Chris - I think I've quoted you more than almost any other scientist, doctor and so on in my career communicating science and medicine because you used extremely frank language and said, 'look, the threat from this is worse than the threat from terrorism.' Which, given what had been happening over the course of the time that you were CMO, that was really saying things. And I think that startling statement helped to crystallise it in many people's minds.

Sally - I've started calling it the Grand Pandemic. After all, we know in 2019, 1.3 million people died of AMR, these superbugs. It's the third most important underlying cause of death in the world. So the idea that infectious diseases are no longer important, COVID scotched, but actually there are all these others which we used to be able to treat very effectively and increasingly we're having problems.

Chris - Did we sleepwalk into this a bit because I'm a bit younger than you, but when I applied to university, I applied to, it wasn't your College Trinity, it was a different Cambridge college. And the 17 year old me sat in their medical school interview and this bloke said to me, 'what do I think the big problems are going to be in the future facing the medical profession?' And I said, bearing in mind I was 17 years old, I said, 'well, I think based on my reading and understanding, we've got a crisis of antibiotics coming.' And I said, 'and I think we are looking at a situation where we might not be able to treat some diseases.' And this guy laughed at me. He told me, I think we're a bit more ingenious than that young man.

Sally - Well, he was wrong and you were right. How very perspicacious of you, I must say. Yes, we've sleepwalked into it. And some of that is the way we'd pay for antibiotics. That most of them are what are called generics. They're made by companies often in India, very well. They do the trick unless there's bacterial resistance, but they're so cheap that it means that health systems, not just ours but around the world, are not used to paying enough money for new drugs that it's worth the companies making them. They make a loss on the research and development. It's not even that it doesn't make them money. And yet it's stupid. We will pay £100,000 to give someone who's got cancer an extra few months of life. But we baulk at £10,000 to save a life from an infection. We just have not thought through our priorities.

Chris - One person who first put me onto the reason why this might be, I sat down with Mene Pangalos from AstraZeneca and he pointed out to me, 'look, we might have to sink 10 billion into making a new drug. We might fail 90% of the time, not because we're no good, but because we're so good that we only fail 10% of the time.' But he said, 'if we come up with a wonder drug and, and we get it on the market, it comes to someone like you pointing his finger at me as a microbiologist and said, what do you do with it? You put it on the shelf and you don't use it because someone like Sally says, you need to keep these drugs as drugs of last resort.' He said, 'either way, we don't make any money. So we're just not able to recoup our 10 billion risk that we've taken or more.' They must have come to you with those sorts of points. So were you able to try and come up with a way to deal with that because it's a broken business model as you've just pointed out?

Sally - Absolutely. So what I persuaded both the NHS and our government to do was to try a new methodology for paying for antibiotics. And we did a couple of pilots that were very successful. Essentially, we put in place an evaluation using NICE but also academics from York University to evaluate the impact of new antibiotics to specific ones on the patient. That's normal. But in addition, on the insurance value of that antibiotic as a fire extinguisher. The value of protecting the whole of that community, that hospital, the community society from that infection. And in that way came up with a larger valuation than you would for an individual. And then multiplied it up by how much we should fairly pay related to our English GDP to the rest of the world. And we've managed to sign contracts with both those companies that each get £10,000,000 a year for the next 3-10 years because it can be renewed after the first three years. And it doesn't matter how much we use it. So we can use as much as we need, but if we don't use it, they still get £10,000,000 a year. The NHS and the patients win. The companies have a steady income. The Americans are looking at something similar. The Japanese announced a pool mechanism, that's what it's called. And if we can get all the G7, the rich countries to do that, then we will have a flow of new drugs.

Chris - One of the problems with superbugs is that, just as we saw with COVID, we've seen with flu, microbes do not need passports. They don't observe borders. They go where we go and sometimes where other animals that carry them go. Antimicrobial resistance is no exception. Therefore, we need a sort of joined up strategy around the world. Have we got buy-in from many countries? I remember going, when I was in America, I went across the border into Mexico early in my medical career and was gobsmacked to walk into a pharmacy and I could buy any antibiotic I wanted off the shelf. That is not going to help.

Sally - Unfortunately, there's still far too much of that. But we are getting traction around the world. I think 115 countries have now got national action plans following work the British government has done with the World Health Organization, Food and Agriculture, Organisation for animal health across the world. And they're beginning to get funding and do things, but still you can go to Africa or Asia and buy antibiotics from a market stall. They may be worthwhile antibiotics, they may be counterfeit. You may only buy one day. All of that drives even more resistance. So we really need to continue to work on this. And I'm very excited because next year on September 24th, there's going to be a high-level meeting. So in the week of the heads of state at the United Nations in New York, we're having a whole day meeting on AMR. And I hope we can really make progress there.

Chris - Has this begun to bear fruit though? Are we seeing that pipeline that was woefully empty begin to be replenished? New drugs coming, new prospects on the horizon to treat some of these superbugs?

Sally - So we've got biotech companies around the world beginning to develop them. So I'm optimistic, but unfortunately we've even had a biotech, who got a licensed antibiotic, go out to business, go bust, because no big pharma bought them because they said, 'huh, we won't make money from it.' So we still have a broken model, though there's some good research coming through. We can do this, but it needs more money. But I promise you prevention and doing this will be so much cheaper than losing all the lives and the cost of not doing it.