Mr. Rohit Malpani
Director of Policy and Analysis
Médecins Sans Frontières
With the release in May of the final report and recommendations of the Review on Antimicrobial Resistance, GBCHealth has convened a group of global leaders to discuss the potential impact of AMR and their priorities for immediate action. The #GBCtalksAMR series, which will be published over the next three weeks is intended to supplement the high-level meeting on AMR that took place at the UN General Assembly meeting on 21 September, 2016.
Is there something particular about the challenges posed by AMR that make coordinated, multi-sector action even more essential?
Antimicrobial resistance (AMR), and the public health challenges caused by AMR, are not an exception but a symptom of a broader ‘disease’. With respect to health, MSF considers AMR to be caused by at least three systemic failures: weak health systems, neglected investment in health care workers and a broken system of biomedical research and development (R&D). To respond to such systemic failures, the efforts within health care must be multi-sectoral, and led by governments. AMR also requires actions across many other sectors and systems – including our food system, our farming system and our stewardship of the environment.
We must also ensure that more is done to build an effective response, and movement, within civil society. No transformative change in health has been possible without the involvement and leadership of civil society, and success in addressing antimicrobial resistance will be no different. Without such leadership, energy and action, the words in reports and Declarations will not be acted upon, and neither government nor industry will be held to account to make the necessary changes that antimicrobial resistance demands however difficult they may be.
Not only does the response to AMR require multi-sector action, but it must also be ‘multi-factorial’. All five objectives of the WHO Global Action Plan are necessary to respond to AMR. As regards the fifth objective on the need for new economic models for the development of medical tools needed to combat AMR we must aim to ensure appropriate use of existing antibiotics, affordable access to existing and future medicines, diagnostics and vaccines, and sustained investment in research and development for the medical tools of the future to diagnose, treat and cure infections.
How can the private sector be an effective partner in the global AMR effort?
We emphasise that first and foremost the response to AMR must be driven and led by governments. Companies should not undermine or block these efforts. Pharmaceutical companies must do more to ensure access to existing medicines and vaccines. More people still die today from a lack of access to existing medicines and vaccines than from resistance. Consider that the pneumococcal vaccine (PCV), which can both save children’s lives and reduce antibiotic use, remains unaffordable for many countries and parents around the world. Global PCV coverage is stagnant at 37 percent, and the unaffordable price remains a significant barrier to protecting more children.
Pharmaceutical companies must also stop lobbying for rules and approaches that have not worked. Stricter levels of intellectual property protection are not a solution to the lack of innovation and access for antibiotics, and for many other areas of public health need. In fact, relying only on patents and other market monopolies as incentives has led to a three-decade innovation gap in antibiotic development. For example, with respect to TB drug development there were no new drugs developed to treat TB for nearly 50 years, despite the fact that TB is now the leading cause of death from infectious disease. Drug companies must stop pushing for ever-stricter levels of monopoly protection through free trade agreements or unilateral pressure upon governments.
Furthermore, pharmaceutical companies should openly support and speak out in favour of new models of research and development that break the link between investments in R&D and the expectation of high prices. MSF is supporting one such model of research and development to develop new regimens to address drug-resistant Tuberculosis (TB). Our goal is to have at least one novel regimen, in the next decade, to deliver vastly superior results to effectively treat all forms of TB.
The project, known as the 3P project (Push, Pull and Pool), is a new approach to developing affordable, effective TB combination treatments. At present, drug-resistant TB requires up to 24 months regimen of drugs and painful daily injections that can cause terrible side effects, including permanent hearing loss, psychosis, and nerve or liver damage – and only 50% of people are cured. The 3Ps uses an open collaborative approach to conduct drug and regimen development and uses novel approaches to finance and coordinate the process – crucially, it doesn’t rely on high prices for its financing, so affordability can be built in from the start.
How can we ensure that all economic and social segments are included in efforts to address AMR?
As mentioned before, we believe that such inclusiveness is only possible through civil society participation and leadership. While we support government leadership and top-down approaches, we must also have a bottom-up approach that harnesses the voices of communities and people affected by antimicrobial resistance, and the front line health care workers which ultimately must develop and inform a collective response.
The particular health needs of developing countries, and the voices of such countries’ governments in priority setting for research and development, is critical. All governments should also play a role in setting principles which safeguard access and affordability. Priority setting and access – if left to high-income countries and the pharmaceutical industry – risk consigning the health needs and priorities of low income countries to charitable half-measures. We believe that the World Health Organisation, as the agency charged with promoting and protecting human health, must take the lead role in ensuring appropriate priority setting and setting standards and conditions to ensure access.
How does MSF address AMR when thinking about patient care, educating patients and prescribing practices?
First, we stress that MSF is approaching AMR with humility. MSF also has significant room for improvement on how we respond to AMR, and are looking at our own medical practice, which can be challenging in humanitarian contexts, and learning every step of the way.
Many of the challenges that MSF faces reflect the contexts where we work. The lack of appropriate tools, particularly diagnostic tests that work in resource poor settings to accurately establish the level of resistance are not available. There are important surveillance and data gaps in many countries we work, however, everywhere we are able to look, MSF finds resistance. We see AMR in the war-wounded people we treat in Jordan, in newborns in Pakistan, in people in our burns unit in Iraq, to multidrug-resistant tuberculosis in communities across the globe. In the Middle East, we are seeing critically unwell burn patients with high rates of multi-drug resistant (MDR) pathogens. We are seeing high rates of MDR pathogens in patients with conflict-related orthopaedic injuries also – many of whom have multiple surgeries in field hospitals before reaching definitive care. It is however unclear whether these MDR pathogens are environmental, due to delayed definitive care, exposure to broad spectrum antibiotics, or hospital-acquired infections.
Our experience shows that where we work we need to train and support health care workers and populations regarding rational antibiotic use and resistance and that it must be done in conjunction with an increase in microbiology laboratory capacity, appropriate and affordable point of care diagnostics and infection prevention and control. Appropriate use needs to also be managed in out-patient settings – this will require working with communities and health ministries.
- Dr. David Barash, Executive Director, Global Health Portfolio & Chief Medical Officer, GE Foundation
- His Excellency Juan José Gómez Camacho, Permanent Representative from Mexico, United Nations
- Dr. Monique Eloit, Director General, World Organisation for Animal Health
- Dr. Nafsiah Mboi, Special Envoy, Asia Pacific Leaders Malaria Alliance (APLMA)
- Ms. Maria Helena Semedo, Deputy Director-General, Coordinator Natural Resources, Food and Agriculture Organization of the United Nations
Director of Policy and Analysis, Médecins Sans Frontières
Rohit Malpani is Director of Policy and Analysis at Médecins Sans Frontières’ (MSF) Access Campaign. Prior to this, Mr. Malpani was Special Advisor, Policy and Campaigns Unit for Oxfam Hong Kong. Previously, he served as Senior Campaigns Advisor at Oxfam America – an international development and humanitarian. Previously, he worked as a human rights advisor to the World Health Organization and the International Labor Organization, and also with local civil society groups in Thailand and Argentina. Mr. Malpani started his legal career as an intellectual property attorney with the law firm of Wilson, Sonsini, Goodrich and Rosati. He has a Doctorate of Jurisprudence from the New York University School of Law and a Bachelor of Arts from Rice University.