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Hello, everyone. Welcome to this Oxford Martin School discussion,

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which is the latest in the series building back better lessons and opportunities from the COVID 19 pandemic.

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We're talking today about the challenge of antimicrobial resistance,

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and I'm pleased to say that with us is one of the most articulate speakers on the nature and scale of the resistance problem,

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and also one of the most energetic advocates for solutions.

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Sally Davies. Dame Sally Davies has been chief medical officer for England and chief medical adviser to the UK government.

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In that role in the UK, amongst many other things,

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she founded the National Institute for Medical National Institute for Health Research, I should say.

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I personally first felt her influence when I was an insider at the World Health Organisation.

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At that time, she served on the executive board of W.H.O. on behalf of the United Kingdom,

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but more importantly, perhaps and certainly more relevant to our discussion today.

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She was a joint convenor of the United Nations Inter-Agency Coordination Group as it was called on antimicrobial resistance.

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And this is not merely an honorary role.

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I was well aware at the time that she really got the wheels turning on the international dialogue on antimicrobial resistance.

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She was a real force behind it. Now she is UK special envoy on antimicrobial resistance and also master of Trinity College Cambridge,

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and you can see the splendid surroundings in which she now finds herself at Trinity.

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She recently launched the Trinity Challenge, which aims to better protect the world from global health emergencies.

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So that really is building back better,

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and I think we'll come to the Trinity Challenge a little bit later in our conversation just before we get started.

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A little bit of housekeeping as crowd cast loyalists will already know.

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You can ask a question while we're talking.

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You'll find the slot at the bottom right of your screen, or you can vote on the questions that other people pose.

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And towards the end of our conversation, I'll select the composite.

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The questions, the ones that have been most voted on and put them to Sally on your behalf.

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You should also know that this is being recorded, so if you do pose a question, you're likely to be on the record.

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All right with that. Sally, welcome. Thanks very much for joining this conversation.

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You're the best person to have to discuss antimicrobial resistance.

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And I like I'd like to start with the the basics because even though antibiotics have only been widely used for a few decades,

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really within the space of a single human lifespan, we now take them totally for granted.

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So could you just say a few words by way of introduction about their importance to medicine and health today?

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Thank you. It's great to be here at the Oxford Martin School again.

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Actually, I've been before on Amazon and always had good conversations.

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So think back to the First World War.

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Think back to before Flemming. What was it like when we couldn't treat infections effectively?

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Someone could get a scratch on their chin from shaving that could develop into an osteomyelitis of the jaw or septicaemia and even lead to death.

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In fact, one of the earliest patients to receive penicillin was a child.

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I think at Johns Hopkins, about six who scratched her face in the garden,

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the swelling of the infection began to block her for so she couldn't breathe.

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She was going to die. But it saved her. So it gives us modern medicine.

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But more than that, as medicines developed, we've been able to do complex operations, many of which need antibiotic cover.

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We've been able to change the life of people with HIV. You need antivirals.

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Those antimicrobials, we don't have much TB in the UK.

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That's because of effective treatments. But I also want you to think about really modern medicine cancer treatment.

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Modern cancer treatments and the underlying disease make people more prone to infections.

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I'm a haematologist. I used to have leukemic patients and they were always getting infections.

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Antibiotics, antifungals save lives. And you couldn't do transplants.

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You couldn't do safely caesarian sections. So it's a disaster.

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That's the human health. But think about the food chain.

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Animals get sick. Unlike humans, they pass the infections.

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So our food chain is stabilised by being able to treat sick animals, whether they're terrestrial or aquatic.

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And, you know, fish farming needs effective treatment of infections.

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So we need and have effective antibiotics are the ones that in the main were worrying most about.

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But just remember, one of the biggest causes of death from not responding to treatment is TB across the world.

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And of course, not only does it impact human health, but it impacts livelihoods, families, happiness and the economy.

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And perhaps you'll want to come back to that.

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But the economic impact we now know about from COVID, it's pretty significant already with animal antimicrobial resistance.

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Some people say that one of the reasons we've become so reliant on antibiotics is because we don't do enough to prevent infections in the first place.

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And indeed, that's part of the argument that preventive health care has been neglected.

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Others say that, well, if we didn't have antibiotics, we could just substitute for them with vaccines.

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What do you say to both of those things? Well, I think that's simplistic.

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We do need to make sure people are properly vaccinated with the vaccines that are there.

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And if you look at the anti pneumococcal vaccine and the impact of saving lives, but also antibiotics, it's immense.

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Flu vaccine actually also saves lives not just by preventing flu, but people,

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particularly old people or vulnerable people with flu about to get bacterial pneumonia.

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It saves people from that. So vaccines are very important.

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We may well come on to the role of vaccines in the food chain. I'm particularly interested in vaccines in aquaculture fish farming.

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So I would argue we need more vaccines and we need to deploy them better.

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We also need effective infection prevention and control. And I think, however, that's woken the world up to exactly that again.

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Look how we've hardly got flu this year. We didn't even notice it this year.

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And that's because it's not here because of infection prevention and control, social distancing and mask.

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But even when people didn't have antibiotics, they still caught infections and they still got very ill and the number died.

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So no, it's too simplistic. But please prevent infection through infection prevention and control,

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washing your hands and across the world from having effective clean water and good sanitation.

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Wash, as you and I call it, Chris from your W.H.O. days.

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Those are essential, but we are now trying to change the debate from a.m. Directives are important treatments

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to actually you can't have a modern health system and a sustainable health system.

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Universal health care without infrastructure. The infrastructure includes clean water and good sanitation and anti-infective.

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You yeah. So antimicrobials or antibiotics? Their existence is certainly not an excuse to ignore prevention and in fact,

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that the whole spectrum of the whole package needs to go together along with vaccination as well.

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Agreed. Let's just talk a little bit about how antibiotic resistance arises.

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Back in 2013, you famously wrote a little book called The Drugs Don't Work.

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Actually, it was the title of a song by The Verve as well. But their drugs were.

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They were talking about something else.

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But how does antibiotic resistance arise and biologically, and how does it spread through bacterial populations?

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And perhaps you could just comment on a few of the most important resistant infections bacterial infections at the moment.

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OK, so it's a natural phenomenon. Our genes all over the kingdoms of animals and sex plants are perpetually mutating and changing,

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and most changes just disappear because they don't give us survival advantage.

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But if a bug, whether it's bacteria virus,

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a fungus parasite infects the human and you're taking an antibiotic and that mutation gives you a survival advantage,

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in fact, you don't die in the presence of the antibiotic, then clearly it's going to spread.

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And the interesting thing is, it may be in the actual genome, so it spreads just children of it and offspring.

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But remember that bacteria multiply every 20 minutes so it spreads very quickly,

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but they can also be passed horizontally to their cousins and their friends by both by dropping

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the genes off and then plasmids into plasma or some other liquid where other bugs of the sea,

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the waterways. Or actually, by putting out a proboscis and shooting the gene into another bacteria,

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they can then share them with their friends and cousins will all pass to their offspring.

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So you can see how once it's got there and it's got a survival advantage, they spread very easily.

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And I think what is really important is how they can spread from one species to another.

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So if you've got a resistance in the Makola, it can spread to Klebsiella and then it can move on to a bacterial something,

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and that makes it very, very complex and difficult.

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And we know that drivers to develop resistance are therefore mistreatment,

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undertreatment, counterfeit and falsified medicines, and generally they're overuse.

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I've got a wonderful slide which just shows for Europe the quantity of antibiotics versus the resistance levels.

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And guess what? It's a straight line straight up, so we know that.

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Now you asked me a second bit the question which was the question.

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The question is, are we talking about many, many different kinds of bacteria but being resistant?

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So a very wide spectrum of problems? Or are we talking about a few dominant infections that really are the principal problem we face today?

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Well, it can spread everywhere and you get outbreaks of different sorts of infection in places.

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So in one part of England, there's an outbreak of CPE, which is very nasty and it's been going on for years and they've not managed to clear it.

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And it does kill people just to CBP's cover for those who resist carbapenem resistant yes.

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Bacteria, yes. And it's a really unpleasant one.

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And that particular part of Britain has not managed despite support from Public Health England over the years to eradicate it.

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So every time they think they're getting there, it pops back up. Remember, in the noughties and across Britain, the MRSA and how that also killed?

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And that was a big problem.

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But at the moment, that's not such a big problem in the NHS, but take other bits of the world and they are at the moment across Europe.

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It's the drum negatives, including in Britain, Klebsiella E. coli and aids in the sector.

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But of course, if you go to Russia, it's MDR and XDR TB.

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So it depends on both the spectrum of disease and infections that you have and how you use your antibiotics.

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Yeah, and it seems to be the case that almost every bacteria can become resistant to antibiotics, with one or two notable exceptions.

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I'm thinking of syphilis. For example, Treponema, which has never managed to find a way to become resistant to penicillin,

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although it does become resistant to second line drugs.

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But despite the diversity of mechanisms that you've talked about, or perhaps because of the two mechanisms,

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almost all bacteria will become resistant once they are treated,

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which which presents us with a dilemma with regard to control, which I'll come back to in a few moments.

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But before we get to how we solve the problem, so few more words about the scale of the problem that we face and what we know about it,

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and whether or not we have the data actually to say how big the problem is around the world.

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We've got pretty poor data. The data suggests.

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That across Europe, about 25000 people die every year of drug resistant infections, about 23000 every year in the US.

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They do have data where they reckon that two million people every year get antibiotic resistant infections are English.

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Data is over 60000 antibiotic resistant severe infections in 2018.

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And amazingly, it's one hundred sixty five new antibiotic resistant infections of serious nature every day,

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and that's gone up by nine percent on the previous day. So it's pretty bad.

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It's much worse, of course, in low and middle income countries. And we can talk about the drivers of that.

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And, you know, we really do have to work this through.

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The World Bank did a study, and they reckoned that if it went on at the present trend by 2050,

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an additional 28 million people would be driven to extreme poverty.

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Our own Jim O'Neill's report. Right. And it was going to cost us trillions, 100 trillion actually by 2050 and 10 million people would die.

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Yeah, but you know, it is a significant problem and it is steadily rising.

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So this is the slow pandemic as compared with the acute pandemic of COVID.

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Mm-Hmm. Just a little bit more about the UK because we don't seem to be doing very well in the UK.

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There is a, as you well know,

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a standard drug resistance index calculated by CDP outfit based in Washington that monitors and tracks antibiotic resistance and,

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according to their data, their resistance statistics. So this is a score out of 100.

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It's the UK about 50 per cent at the moment, and that compares with India, which is over 70 per cent.

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That's worse, as you have suggested for low income countries, but compared with Sweden, which is less than one percent.

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Why is the UK so much worse than Sweden at the moment?

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Well, it's very interesting that the use of antibiotics in humans and animals goes down as you go north in Europe and increases as you go south.

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Resistance goes down as you go north in Europe because they're using less and increases as you go south in Europe.

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But we are in the better part of Europe, though behind the Scandinavian countries.

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And one can debate whether the fact they have smaller populations, less overcrowding, less poverty and all sorts of things like that matter.

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But let's look at the bit that we do know about.

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We know that in in England, we have reduced our use in general practise by 11 percent over the last few years.

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We know that in the hospitals in England, we've stabilised it so its use is not going up,

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which is unusual for developed countries and low middle income countries, despite its stabilised despite increased throughput and complexity and age.

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So I think that's pretty good if you then look at the animals sector.

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They reduce the use by 50 percent, actually over 90 percent in chickens, and they've done all of that voluntarily.

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So I don't think it's such a bad picture, but what we can see in Britain is variation, too.

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So one way of measuring it is daily doses per thousand inhabitants per day, and we've got variation.

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So two counties relatively close to each other in the north of England,

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one is running at sixteen point one daily doses per thousand inhabitants, the other at twenty seven daily doses per thousand inhabitants.

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So we've got a way to go in stewardship, which is looking after our antibiotics better and in,

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as well as we need new ones and we need better data, but I'm sure we'll come to that.

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And what I've been very careful to do as I've worked on this is to make sure this isn't a blame game.

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We're all in this together and we have to get it right together and not blame.

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And I think that's one reason why our animal sector have come on the journey with us voluntarily and made such a big difference.

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Let's just clarify the use of antibiotics in animals.

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They used Huntly inventory practises to treat infections, as you said at the beginning, but they're also used as growth promoters,

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and some of the antibiotics that are used as growth promoters are the same as the ones it used in human medicine.

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And so their use in animal husbandry worsens the problem that we face with regard to human medicine.

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But how much of a contribution is that from the animal animal population?

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Is it a major contribution or are we are we talking principally about the way in which human antibiotics are used by humans?

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Or is it the case that they use in in animals and agriculture and aquaculture, as you said earlier,

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is a major contributor contributor to the to the human problem of human resistance problem as well.

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So we know that human use is probably the biggest driver at this point.

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But growth promotion and prophylaxis are an excuse for poor practise in animal husbandry.

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So why take that risk when we when there is ample evidence that those animals do develop drug resistant

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bugs on them and in them that can then be passed across or spill over into the human population,

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particularly during handling in the abattoirs in food preparation, but also if not properly cooked and everything.

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So I think there's a nice Canadian study which doesn't prove it,

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but wonderful close association between using antibiotics and the antibiotic resistant bugs in chickens,

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the bugs appearing in the chickens and then the leg phase. They appear in the humans.

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So then they stop using it in the chickens and they go away and then they challenge the chickens again.

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Then they comes back in the chickens and then the humans.

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So meanwhile, we've got studies of their use in aquaculture and around which worry me about the environmental contamination of how that might impact.

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So antibiotics appeared and pulled out by animals, which includes humans and pigs,

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chickens, fish more than 70 percent, generally over 90 percent, difficult to break down.

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So a study of rivers across the world showed that even the Danube and the Thames have at least one antibiotic visible in them, though some are clean.

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But it's not just the problem of low income countries.

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Meanwhile, Essex University do a rather nice study that they repeat regularly on their surfing beaches where their students go,

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which is called beach bums.

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And they've shown that the incidence of antibiotic resistant bugs in the water has gone up three times over the last decade,

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so we know the risk is going up.

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And what I think most people don't recognise is it's not just you might catch that one of these bugs through a cut or something.

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Actually, many infections, particularly with cancer or pain, stop come from your own gut,

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your microbiome, because your weakened or it's the some way it can enter the bloodstream.

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And if you've got antibiotic resistance in your microbiome, which you just acquired and generally doesn't matter,

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then your urinary tract infection, your sepsis, whatever it is, it's going to be difficult to treat.

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So we need to keep people healthy, and we don't want this transmission of resistant bugs,

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either from the surface water paddling and drinking the river when you fell in and swam or from dirty food.

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I referred earlier to the dilemma of treatment with antibiotics, and the dilemma is this as I see it,

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it's a striking statistic that most people in low income and middle income countries don't die from antibiotic resistance.

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In other words, the treatments don't fail. It's that they don't get treatments in the first place.

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So people who carry infections need antibiotics, and they're getting antibiotics in growing quantities.

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But as you said earlier, once they get those antibiotics, that drives up resistance.

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So how do we solve that fundamental dilemma?

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We want to get antibiotics to people to treat the infections, and we know that those treatments will work at least initially.

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But how do we do that and at the same time, prevent the growth and spread of resistance?

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It is tragic. There's a cholera outbreak that started in Hyderabad, and it's resistant to standard treatment and has moved into Karachi,

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and 40 percent of the children are now dying who catch it because it's antibiotic resistance, whereas normally it would be four or five percent.

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So it's tragic. They need treating, but they're not responsive.

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And so we have to help the low income countries to a number of things.

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First, strengthen their own health systems, including the sanitation, clean water,

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infection prevention and control and the standard vaccine programmes.

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We also need to make sure that they do have a proper supply at an affordable price of good quality antibiotics,

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and that means we're going to at some point have to deal with the fact many antibiotics in poor countries are sold at market stalls.

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Over 50 percent of the antibiotics on market stalls are a falsified or counterfeit, not good enough quality that's driving resistance.

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But the other driver resistance is even if you can afford a day that might drive resistance because you're not killing the bugs,

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you're exposing them, and you may not be able to afford the rest of the five seven 10 day supply.

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So we have to sign up to universal health care for all in order to try and make sure they have to strengthen health systems of hope.

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But then add to that the fact that most people don't know the signs of the problem and they see that report you were talking about,

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I think shows up very well. So then what do you do?

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We've got to help them with laboratories and surveillance.

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And in fact, we have in Britain the Fleming Fund, which is 250 million or more of overseas development assistance and we've been helping.

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I think we're helping 24 countries develop their laboratories, their surveillance to really good standards so that they can get on top of the problem.

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They and start to work out their own antibiotic grams, biotic grams,

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whatever they are and do better is it is it inevitable that all bacterial infections

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will become resistant to antibiotics and all we can do is just slow that down a bit?

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Or can we preserve the antibiotics we've got at the moment indefinitely by doing the right thing?

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I think we can preserve them for significant periods,

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because there's no doubt that went when the police cleans their act up, the resistance does go down the levels.

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But it's one of the reasons we've got a broken pipeline with next to nothing in it is, you know, if a company produces a new antibiotic.

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First of all, we're not used across the world paying money for them like we pay for cancer drugs.

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They're cheap, so they're not going to make much of a profit. Secondly, resistance is likely to start before the end of the patent life.

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So they're actually then going to find it difficult to sell.

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So and at the beginning, people seem to find it difficult to move into new anti-infective so like new cancer drugs.

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So everything is against developing new drugs.

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But in the end, we're going to need much better prevention IPC vaccines and everything,

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much better looking after what we've got and knowing the problem and new treatments and going alongside those,

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we need better, cheaper, faster diagnostics so that you I mean, one of the solutions will be less broad spectrum antibiotics and more narrow spectrum.

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But then you need to know what the bug is and whether they've got resistance to get the right antibiotic.

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Mm-Hmm. The the COVID pandemic has taught us a lot about infection control is taught us a lot about hygiene, sanitation as well.

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What do you think the COVID effect will be here on anti-microbial resistance?

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Do you think there will be a big move for better infection control in hospitals, for example?

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Or will that just be a temporary fact that wears off once we begin to forget

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about this pandemic and people are no longer wearing PPE in clinical settings?

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Well, if you look at MRSA, we took it on board for about five years and then the hand-washing dropped and we had to have another campaign.

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So I fear that we're going to have to always keep teaching people these behavioural things.

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So that's one issue. The other is what's happening to antibiotics and resistance actually during COVID.

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And unfortunately, the best study I've seen is mainly Asia.

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But in wave one, where you'd expect somewhere between three and 10 percent of patients on

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ventilators to have superimposed bacterial infections and to need antibiotics,

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70 percent or more of patients are being given antibiotics.

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And I know it's very difficult, but actually W.H.O. and our own guidelines are don't use antibiotics for COVID.

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It won't work. You're just driving resistance and costing money.

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We were talking a little bit about. The success we could expect if we do the right thing with respect to managing antibiotics,

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and it struck me observing this from a distance that we actually don't do enough to say what the rewards will be with regard to good practise.

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I'm really from my own work on tuberculosis, for example, that if you treat patients correctly with anti tuberculosis drugs in the right combinations,

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you can not only force resistance down in populations, you can actually make multi-drug resistant TB go away faster than drug sensitive TB.

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But I've searched in vain for good compilations of all the evidence in the literature for all antibiotics and all resistant infections,

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for the successes that we can achieve if we do the right things.

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Does it exist state or have we just not been good enough at compiling that evidence?

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Well, part of it will be that we have been good enough at compiling it.

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It is interesting, though, that we've now have reported from the high Amazon and the Arctic bacteria that are resistant,

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and yet they haven't had the exposure to the antibiotics that anyone can possibly work out.

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I'm not saying that, just they can't work it out. So some of this is just happening anyway.

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Can we put it back in the box when we clearly can put some back in the bolts of TB?

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Example is one, and there are other examples in countries where they do eliminate something or drop it really low.

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And of course, in general, what I'm told by the experts microbiologists is that if you've got a resistance gene,

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you probably haven't got a growth advantage against the normal bug.

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Without it, you've probably got a disadvantage. So generally, and this is what seems to happen mostly in the microbiome after some months,

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the the hampered because of having an allergy named bug is outgrown and disappears.

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I'd like to know a bit about your views on the pharmaceutical industry and where they stand in this.

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They stand accused of two things, essentially. One is failure to invest in the development of new antibiotics.

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But on the other hand, some of the science behind that is rather difficult.

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And on the other hand, not even manufacturing enough of the antibiotics that they already hold patents on, which contributes to the lack of supply.

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For example, in low and middle income countries. So on those two charges against the pharmaceutical industry, where do you stand?

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Should they be doing more? Oh, yes, of course they should do more.

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I don't think they're nuts not to.

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And I'll tell you the nuts because they may in general make their profit from anti-cancer medicines or renal failure medicines or diabetes medicines.

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But all of those people are more prone to infections. And if you haven't got effective antibiotics and antifungals and antivirals,

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then actually their main product lines that make them a profit are not going to be used in the long run.

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So, you know, I think they're being shortsighted in thinking about short term profits.

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Some of them, they're all companies who do it,

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but we do have a broken pipeline and it is that market failure that it's very difficult to pull them through because we don't pay enough.

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And actually, ideally, I would like you to give me some new drugs and I'll lock them up, get them out.

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For certain patients who really need their lives saving well, all patients need their love saving, but that drug would make the difference.

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And we've seen Melinda in L'Aquila and go bankrupt. You know, they had good drugs.

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They were registered drugs. Interestingly, the Arcadian story gives us another take on all of this.

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It was the the antibiotic was bought by a generics company who have chosen not to register it in the EU because

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it would cost them too much to register it in the EU because you have to do all these paediatric trials.

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So there is an effective antibiotic available in the states that is not registered for

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the EU or in Britain because it's too costly for the amount of money they'll make.

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And then you look at low and middle income countries,

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and quite a lot of antibiotics are not registered there because each country has a different regulatory process and then demands different packaging.

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We're going to have to move to pooled procurement. We're going to have to move to kind of much more regional agreement that this medicine

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matters and it looks safe and you can have it in order to get through some of these things.

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But also, we need some way of putting market incentives in that don't have the companies

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making their money from volume sales because volume sales drives resistance.

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So Britain is actually leading the way. We have got a pilot and is being run out of nice with support from your health

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economics unit and the industry are involved in which is a subscription pilot.

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They've chosen through EU contractual process two antibiotics, one from Pfizer, one commission.

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And what they're doing is using them properly stewarded because the company will get a subscription.

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However, much or little is used, and they're using a new health technology assessment procedure,

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which doesn't just value the drugs for the individual patient and qualities and values.

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It's looking at the value to the NHS and preventing that infection and not letting it spread.

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It's looking to the value to to society, and that will give a different value, the total value.

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And that is what the future negotiation about the longer term subscription would be.

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And everyone's watching this and industry playing their full part of the debate, the discussions, and I think that will be good.

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But one thing I should well, two things I would say positive about industry.

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Without them, we don't get drugs. You may find mechanisms and targets in academia.

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But the development, the launch, the marketing, the manufacturing is with the companies.

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The second is, of course, that they did last year launch the AMR Action Fund along with the Wellcome Trust and the European Investment Bank,

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with a billion dollar fund to pull through three to four drugs over the next 10 years.

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So they're putting some money where their mouth is.

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I'd like to see more before we leave the pharmaceutical industry and indeed the basic science behind antibiotic development.

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What about the hard science question?

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You know, the observation has been made many times that once we discovered how to find antibiotics 1930s, 1940s and so on,

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we basically picked all the low hanging fruit in the next two or three decades, and then we ran out of options.

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And since the turn of the millennium to 2000, I think only two new classes of antibiotics have been discovered,

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and some say that it's just hard to know where we must go scientifically with regard to antibiotics.

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Others say that if there's enough money invested in the science and in the pharmaceutical development.

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And we'll find them. And it's just a matter of lack of investment, so there's two strands to this debate.

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One is that the science got harder and we're not sure what to do now with antibiotics.

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And on the other hand, we just don't have enough investment. And if we did have it, then we could churn out loads more.

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What's your view? Well, of course, the science has got harder.

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But if you look, there's now a fund called Carb X, particularly mainly funded by BARDA in the states, but welcome all government.

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The Germans contribute. And they've kind of ginned up the research.

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And now you can see from Northeastern University different ways of culturing soil to find new antibiotics.

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You can see from M.I.T. using artificial intelligence, a AI and machine learning to model and find new ones.

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There are new things, so there was something in nature only last week.

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I think because momentum is picking up because industry have set up the AMR Action Fund.

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And of course, we've now got the global leaders group set up by the UN on which I'm honoured to say people are beginning to say,

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OK, so maybe it's worth going into this and they're beginning to find different ways of doing things.

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I'm optimistic. Not that it's easy, but it's doable.

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So just just one more question for me before we come to questions from the audience

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there already 25 questions from the audience and getting some heavy votes.

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And so I want to I want to come to them in a moment.

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But I refer to the time when I was back in W.H.O. and I was aware of how effective your work was at the time.

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And one of the big events was the United Nations General Assembly discussion.

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So this is a so-called high level meeting and high level here in UN.

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Speak means heads of state and there are not many health events at heads of state meetings.

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It was supposed it was the fourth in and I know the other ones as well.

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We won't discuss those now, but that was a real achievement then.

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But progress seems to have been rather slow since. Has it stalled?

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Has the momentum kept up? Yes, it did. I was so pissed off.

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The Inter-Agency Coordination Group was set up following the high level meeting.

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I was a co-convener. The first year was a waste of time.

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The second year we produced some good recommendations presented them to the Secretary-General in April 2019.

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One of them was We needed the global leaders group. Huh?

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We had our first meeting last week. I mean, that's all too long.

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Meanwhile, we also said we needed the kind of IPCC type mechanism for independent,

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generating the evidence for people to look at with respect to policies that still hasn't been set up and started.

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So it is possible. But what's the what's the reason for this?

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Why wasn't the momentum?

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Well, what we managed to do was get David Cameron played a big role, a prime minister along with Angela Merkel really championing it.

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But we're moving back to that position again now because COVID has made people wake up to the fact.

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Plus they can put off doing something much longer. The British, the Swedes, the Germans, the Japanese, many of us were saying,

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You can't go on not doing anything, you know, but but it slowed down before COVID, didn't it?

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And she did jumpsuit. So what did we learn from that experience?

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So we have we have the we have the fanfare, we have the New York events and so on.

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We had other events around the world and then the momentum went out of it.

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What did we learn from that that will allow us to?

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Well, it's been called the silent pandemic. How can we turn up the volume again on the silent pandemic?

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Well, we need more data. I think data speaks if you look at the IPCC and climate change, which is as complicated or I should say,

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is as complicated as climate change, we need the data, we need a.

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That's what I like about the sea that report starting to do kind of dashboards and things.

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I'm hoping that the global lead, this group will endorse a dashboard and look at it regularly and talk about it.

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Data can speak to a lot, but we actually need global leaders to engage with these knotty problems.

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It will need money, but not doing it will cost vastly more.

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And COVID has shown that. And you know, I talk about the lobster and Cove.

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It is the lobster dropped in boiling water, making a lot of noise and dying.

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But Amara's the lobster in cold water heating up slowly.

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It makes no noise. It'll only make noise if it really heats up much more fast.

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But it's going to die. We really mustn't lose the opportunities we've got.

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And that's going to be a high level dialogue, which is different.

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It's not heads of state.

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Actually, at the end of April, we've just heard the president of the General Assembly has invited us to work with member countries to develop one.

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So I think we're getting some of this back. OK, terrific.

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Let's now come to some of the audience questions and this hot competition for the the most interesting one.

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The question now has nineteen votes. Let me take it from the top.

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Do we have this is from Tim Walsh. Do we have any idea of global internet sales for non prescribed antibiotics, non prescribed antibiotics?

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Really important question. How much of an issue do you feel this is?

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It's really mean when your friends start asking difficult questions that are less friendly, friendly fire.

384
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Yes, I will say that we don't we don't even really know in this country.

385
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Every so often I go to MHRA with some evidence because I've just played on the web and look to buy can get hold of antibiotics.

386
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It worries me. You know, if if it's the way to get them, it's just the right, you know, the right answers to a questionnaire.

387
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If you hadn't told the that, you can find the right answers. So this is an issue.

388
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I don't think it's as big an issue as the way antibiotics are used in the food chain or the counterfeit ones.

389
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But you're right, Tim, we will have to get on top of it at some point.

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The next one's from David Sweetnam, who I guess you also know deal that the UK government are in a position following Brexit to put

391
00:45:11,250 --> 00:45:19,470
pressure on the US government to reduce their much greater use of antibiotics in farming and in the EU.

392
00:45:19,470 --> 00:45:28,840
This, of course, the context of this is much broader with regard to trade deals and agricultural practises and standards and so on.

393
00:45:28,840 --> 00:45:33,840
But let's just focus on the antibiotic use in farming. Do you think there's influence?

394
00:45:33,840 --> 00:45:39,660
Do you think pressure can be brought to bear? What pressure can be brought to bear?

395
00:45:39,660 --> 00:45:47,820
Actually, it will be much more effective through that for the Transatlantic Taskforce on Antimicrobial Resistance.

396
00:45:47,820 --> 00:45:53,400
I think because in the end, this is raw politics and there will be trade offs.

397
00:45:53,400 --> 00:45:57,630
Interestingly, though, it's still an issue. And though intensive farming,

398
00:45:57,630 --> 00:46:10,860
the use in animal well known in animal rearing has gone down in the states and the FDA is steadily moving the targets down and down.

399
00:46:10,860 --> 00:46:13,530
It's not good, but it's steadily improving.

400
00:46:13,530 --> 00:46:26,820
So maybe by doing it through the UN and systems like that, we'll have more impact than just through a trade deal.

401
00:46:26,820 --> 00:46:36,690
But I worry about it. Yeah, we'll need to use our international influence more than just working bilaterally, I think.

402
00:46:36,690 --> 00:46:42,600
Let me come to the next one, which is which takes us back to farm animals and essentially vegetarianism.

403
00:46:42,600 --> 00:46:49,530
And there's a variety of expressions of this question, let me say, but let me just put the top one.

404
00:46:49,530 --> 00:46:57,550
Given that the vast majority of antibiotics are used in farm animals, should we all be eating a plant based diet?

405
00:46:57,550 --> 00:47:00,120
I don't think that's the argument for it.

406
00:47:00,120 --> 00:47:12,310
I did, you know that streptomycin, the last resort drug for TB, is sprayed on citrus fruits for a couple of weeks each year in Florida and California.

407
00:47:12,310 --> 00:47:18,100
Did you know that in the Middle East, they inject antibiotics into date palms?

408
00:47:18,100 --> 00:47:26,250
Did you know that other country in Asia injects amoxicillin into citrus trees?

409
00:47:26,250 --> 00:47:37,510
I mean, you know, we are and some of this you have got to treat disease income in plants and crops.

410
00:47:37,510 --> 00:47:42,060
But the question is, are we getting the balance right and that's when you come to.

411
00:47:42,060 --> 00:47:51,420
Well, could we breed plants and trees and crops that won't get infected and then save ourselves from the risks of

412
00:47:51,420 --> 00:47:58,950
using anti-infective to which resistant drugs develop and then pass through and spill-over into humans?

413
00:47:58,950 --> 00:48:05,700
But it's not a simple one. And don't forget, you need B12 to stay healthy.

414
00:48:05,700 --> 00:48:09,090
That question was from Louise Proud and a series of others.

415
00:48:09,090 --> 00:48:17,010
I won't go through all the names, but that was the question that the next one is actually close to one of my own interests,

416
00:48:17,010 --> 00:48:22,410
especially when I was working in W.H.O. This is from Frieda Rumi Hidalgo.

417
00:48:22,410 --> 00:48:28,190
And she asks, What's the role of the law in tackling anti-microbial resistance?

418
00:48:28,190 --> 00:48:38,820
Now I've heard you suggest in the past I think that legal instruments might be too heavy handed and that we should opt for voluntary measures.

419
00:48:38,820 --> 00:48:43,110
My own experience is that voluntary measures don't work too well in health,

420
00:48:43,110 --> 00:48:49,440
and I have been favour of using legal instruments if they can be used, and it was a subject of discussion in the.

421
00:48:49,440 --> 00:48:55,830
But how do you react to that? What's the role of the law in tackling antimicrobial resistance?

422
00:48:55,830 --> 00:48:59,880
Well, it can be incredibly helpful.

423
00:48:59,880 --> 00:49:08,010
So the obvious one is the in the EU, antibiotics are not allowed for growth promotion.

424
00:49:08,010 --> 00:49:17,520
Meanwhile, the further south you go in Europe, the more prophylaxis a metaphor Lex's is used.

425
00:49:17,520 --> 00:49:25,200
So the amounts of antibiotics used are still too high compared with Scandinavia and even also.

426
00:49:25,200 --> 00:49:26,910
But it can play a role.

427
00:49:26,910 --> 00:49:38,340
And they, the EU, have put growth promotion as into their trade deals, so they won't allow import of meat where there's been growth promotion.

428
00:49:38,340 --> 00:49:46,860
So it can work ideally like to see a treaty where which was global, where you know,

429
00:49:46,860 --> 00:49:53,520
treatments of medical importance to humans could not be used in animals and crops.

430
00:49:53,520 --> 00:49:54,570
And that's the thing.

431
00:49:54,570 --> 00:50:05,700
And limiting their use in the food chain to what must be done and promoting infection prevention and control and monitoring everything.

432
00:50:05,700 --> 00:50:11,820
And I think one day we'll probably get there. But the trouble is, we won't get there overnight.

433
00:50:11,820 --> 00:50:15,540
And if I put all my energy into trying to make that happen,

434
00:50:15,540 --> 00:50:23,790
the a lot of deaths that we could have done something about improving stewardship, thinking about some of the other issues.

435
00:50:23,790 --> 00:50:30,150
So it's how do you try and progress that steadily while doing the things that are

436
00:50:30,150 --> 00:50:36,690
pressing that you know you can make a difference with in the context of climate change,

437
00:50:36,690 --> 00:50:43,230
which we alluded to earlier? We have groups of lawyers like Client Earth, for example,

438
00:50:43,230 --> 00:50:52,440
who've been tremendously effective in bringing taking the law essentially to government and say, We're going to hold you responsible for that.

439
00:50:52,440 --> 00:50:56,780
Do we need something similar for antimicrobial resistance? Would it?

440
00:50:56,780 --> 00:51:05,250
I think you'd be great. I think we need much more civil society engagement and pull.

441
00:51:05,250 --> 00:51:09,700
I think we need patient faces. I've talked to the Cancer Research UK,

442
00:51:09,700 --> 00:51:21,510
I've talked to cystic fibrosis and actually they do recognise that they have a duty to try and raise the agenda up because it impacts the patient.

443
00:51:21,510 --> 00:51:27,370
I mean, you know, try talking that I seem to get it or I used to before COVID, get it over dinner.

444
00:51:27,370 --> 00:51:32,400
So what is it? Why does it matter? It just doesn't appeal to people.

445
00:51:32,400 --> 00:51:39,910
We need to find simple ways of talking about it, but we need patients talking about it and the public pulling.

446
00:51:39,910 --> 00:51:46,750
I've heard some people comment in the past that the problem is that it's not a disease because it's not a disease,

447
00:51:46,750 --> 00:51:54,790
it's hard to make the point in the way that you can about emotive diseases, including COVID, including Ebola and including others.

448
00:51:54,790 --> 00:52:00,430
But let me put to you a question this one comes from the front lines of medical care.

449
00:52:00,430 --> 00:52:06,760
Lauren McGivern is a junior doctor who she says she works on the COVID ward.

450
00:52:06,760 --> 00:52:09,100
And unfortunately, I'm reading the question now.

451
00:52:09,100 --> 00:52:16,420
As you mentioned, the majority of our patients are commenced on antibiotics as we have a low threshold to do so.

452
00:52:16,420 --> 00:52:19,660
Have you seen rates of asthma rise during the pandemic?

453
00:52:19,660 --> 00:52:29,140
And if so, how should we, as health professionals, continue antimicrobial stewardship during this time of extreme pressure on the NHS?

454
00:52:29,140 --> 00:52:37,750
I'm sure this is a question that will resonate with many. So, Lauren, let me start by saying thank you doing the work you're doing.

455
00:52:37,750 --> 00:52:43,840
We have a daughter on the front line like you and it's hard in so many ways.

456
00:52:43,840 --> 00:52:55,360
And so you will not hear me criticise people for using more antibiotics than are probably needed or essential because on the frontline,

457
00:52:55,360 --> 00:52:59,770
when you're stressed, you have to do what seems to be the right thing.

458
00:52:59,770 --> 00:53:11,110
My ideal is you do that. And then when a negative culture comes back, someone has the strength to stop it and then you wait and see.

459
00:53:11,110 --> 00:53:16,960
But it's not easy. And as yet, we haven't got the data on the AMA.

460
00:53:16,960 --> 00:53:21,910
We're back to a lack of data. We know we shouldn't overuse them.

461
00:53:21,910 --> 00:53:25,810
But hey, I've been there on the front line too.

462
00:53:25,810 --> 00:53:30,280
You do what you think is right and thank you for doing that. Mm hmm.

463
00:53:30,280 --> 00:53:39,520
A related observation that many people make is that physicians still frequently prescribe antibiotics for viral infections.

464
00:53:39,520 --> 00:53:45,340
They know they shouldn't, but they do. That's different. That's very different.

465
00:53:45,340 --> 00:53:53,320
And there's a lot of patient pool and belief by the behavioural research on this bike.

466
00:53:53,320 --> 00:53:57,190
It's generally in the community GP's that patients want it.

467
00:53:57,190 --> 00:54:03,820
The patient pool is about two things kind of get back to work and get on with life,

468
00:54:03,820 --> 00:54:12,550
or also some really nice focus work done by where patients felt that if they were prescribed an antibiotic,

469
00:54:12,550 --> 00:54:16,810
they could bring up work because they've been validated that they were ill.

470
00:54:16,810 --> 00:54:23,830
The antibiotic prescription was a validation. So actually, we then did some very nice work in the north,

471
00:54:23,830 --> 00:54:28,800
where they have prescription pads and they fill them in and you look as if you've got a viral infection.

472
00:54:28,800 --> 00:54:35,770
This this is what you need to do. Signed, you know, you must stay off work and tore it off and gave it by hand to patients.

473
00:54:35,770 --> 00:54:42,040
And it did the trick on that validation one. So I think there's two sides to this.

474
00:54:42,040 --> 00:54:51,100
And doctors GP's have dropped their use 11 percent over the last few years, so it's steadily improving.

475
00:54:51,100 --> 00:55:03,360
Yes, it's got further to go, but we have to help them. The the next question is very succinct, and it comes from someone whose initials are GM.

476
00:55:03,360 --> 00:55:09,760
Could you say something about disinfectant resistance? Well, I'm not expert at that.

477
00:55:09,760 --> 00:55:14,710
I'm not expert. I'm not a microbiologist and Sharma haematologist,

478
00:55:14,710 --> 00:55:25,450
so we all know maybe 10 should come in and answer this actually that there is increasing resistance to disinfectants.

479
00:55:25,450 --> 00:55:35,200
And I think we all have to start to think should we be using soap and water more or other new technologies in Southhampton?

480
00:55:35,200 --> 00:55:42,670
They've got a professor who does bubble technologies and bubbles can rupture infectious organisms.

481
00:55:42,670 --> 00:55:58,450
So, you know, maybe we need not in a pandemic, but maybe we need less disinfectant and more simple soap, alcohol bubbles or whatever.

482
00:55:58,450 --> 00:56:06,190
Thanks, Sally. Incidentally, if people do feel that they'd like to comment as well as a Christian chat, I think he's disabled while we're talking.

483
00:56:06,190 --> 00:56:08,840
But it will come online just when we stop.

484
00:56:08,840 --> 00:56:16,050
So if anybody wants to provide some comments that others can read, I think they'll be able to do so at the end.

485
00:56:16,050 --> 00:56:24,070
I'm coming to another question which touches on a point that we raised earlier, which is we want to develop new antibiotics.

486
00:56:24,070 --> 00:56:31,450
But and the development has been slow for various reasons, and perhaps we should be taking a new line of attack.

487
00:56:31,450 --> 00:56:36,160
So the next question is about bacteriophages, which of course, how so?

488
00:56:36,160 --> 00:56:40,270
These are viruses that infect bacteria,

489
00:56:40,270 --> 00:56:48,700
and the idea of using bacteriophages has been thrown around for decades and decades, actually as long as antibiotics have.

490
00:56:48,700 --> 00:56:53,530
Where do we stand on that at the moment? Are there any promising developments?

491
00:56:53,530 --> 00:56:57,610
Yes, Rob. Let me go to the question beneath.

492
00:56:57,610 --> 00:57:05,890
The problem is that they're very not just species species specific, but strains specific.

493
00:57:05,890 --> 00:57:15,340
So you need a big library of bacteriophages to find the right one for that particular strain of a bug.

494
00:57:15,340 --> 00:57:21,490
But there is a wonderful story in the states from the West Coast,

495
00:57:21,490 --> 00:57:28,480
where the husband of a public health epidemiologist really nearly died and she

496
00:57:28,480 --> 00:57:35,200
managed after the bugs were resistant to everything to find the right bacteriophage.

497
00:57:35,200 --> 00:57:46,180
Hey, he's back to normal. And I do think that they will develop a role as a team unless they're doing some really interesting work on this.

498
00:57:46,180 --> 00:57:53,320
And I have a dream that, you know, before I go for my replacement hip, you know, at some point and I need one, I don't need one at the moment.

499
00:57:53,320 --> 00:58:00,430
I will drink bacteriophage cocktail to clean my gut before I go in as prophylaxis.

500
00:58:00,430 --> 00:58:04,180
So I do think they have a future,

501
00:58:04,180 --> 00:58:12,610
but it's going to be quite complex and it'll involve libraries of bacteria found and then being able to go through them.

502
00:58:12,610 --> 00:58:18,430
Interestingly, they were developed and used most in Russia and Georgia,

503
00:58:18,430 --> 00:58:23,710
and I've had Russian microbiologist tell me they don't believe they will answer the thing.

504
00:58:23,710 --> 00:58:31,900
But I think surely a monoclonal is to say you can all help in different ways.

505
00:58:31,900 --> 00:58:43,960
There won't be a magic alternative treatment, I expect, but there should be a number of alternatives that help in specific cases.

506
00:58:43,960 --> 00:58:53,960
Here's a chance to just say a little bit more about testing, which I think is really an important issue.

507
00:58:53,960 --> 00:59:00,150
Actually, the order of questions is changing, as I as I read them, but I'm.

508
00:59:00,150 --> 00:59:09,000
What is the status of I'll paraphrase the question, what is the status of testing for antimicrobial resistance?

509
00:59:09,000 --> 00:59:18,610
You alluded to earlier on. Do we need more advances in the diagnosis of antimicrobial resistance?

510
00:59:18,610 --> 00:59:26,710
Yeah. Still, the gold standard is a culture, for instance, of blood culture.

511
00:59:26,710 --> 00:59:31,060
I saw a very interesting audit which show that even in, you know,

512
00:59:31,060 --> 00:59:38,380
top teaching hospitals that are often inadequately done, perhaps it was difficult to get the blood sample or something.

513
00:59:38,380 --> 00:59:44,440
Then they take a couple of days to grow and then they've got to be checked out and looked up.

514
00:59:44,440 --> 00:59:53,110
We need speedy, effective diagnosis for species strain and is the resistance ideally?

515
00:59:53,110 --> 01:00:02,470
And that was why we got the first longitude prise to be for a diagnostic for that would help them all.

516
01:00:02,470 --> 01:00:10,600
It would be cheap, easy to use anywhere and speedy so that you could do it in front of the patient almost.

517
01:00:10,600 --> 01:00:15,610
There's a lot of work needed. Sally, we're just about out of time.

518
01:00:15,610 --> 01:00:20,260
But I'd just like to ask one question.

519
01:00:20,260 --> 01:00:30,990
What is your message to all of us as individuals about what we should be doing personally with regard to protecting antibiotics?

520
01:00:30,990 --> 01:00:35,970
Well, it starts with prevention, doesn't it?

521
01:00:35,970 --> 01:00:49,290
We can prevent infections by good hand washing, food handling, mask wearing, social distancing, all those things and you know them as well as me.

522
01:00:49,290 --> 01:00:55,110
But also we've started an investor action.

523
01:00:55,110 --> 01:01:03,750
People can have a big impact, either as investors or the companies that you, your pension fund is investing in.

524
01:01:03,750 --> 01:01:09,780
If you have a private pension fund that is investing in the food chain that is misusing them.

525
01:01:09,780 --> 01:01:20,010
Are you investing in fast food companies where they buy from companies that are misusing antibiotics as a consumer?

526
01:01:20,010 --> 01:01:27,240
I never thought I'd speak in favour of McDonald's, but they have said they'll take antibiotics out of their beef supply.

527
01:01:27,240 --> 01:01:34,680
If they do, then the consumer has had an impact. So you can have an impact in preventing infections.

528
01:01:34,680 --> 01:01:39,570
You can make sure you accept if it's a viral infection in you or your family.

529
01:01:39,570 --> 01:01:48,120
You take the advice and then insist on antibiotics, and you can have an impact as a consumer or an investor.

530
01:01:48,120 --> 01:01:57,810
And then finally, talk about it to your friends, your family and everyone, because if they only understand, they will help us move this forward.

531
01:01:57,810 --> 01:02:03,480
At the moment, it's a specialist subject, and there are a few of us who understand most of it.

532
01:02:03,480 --> 01:02:12,420
Some really understand vast amounts, but there's not enough people speaking up and saying action is needed.

533
01:02:12,420 --> 01:02:15,930
Well, Sally, thank you very much for joining this discussion.

534
01:02:15,930 --> 01:02:22,380
I'm sure there will be lots of talk around the dinner tables this evening about what you've been saying in this discussion,

535
01:02:22,380 --> 01:02:28,530
and thanks for pushing this forward as as hard as I knew you did when I was in the World Health Organisation.

536
01:02:28,530 --> 01:02:37,800
I just have to say before we go the next talk in this series and you can check it out on the Martin School website is about science communication.

537
01:02:37,800 --> 01:02:44,010
Hot topic at the moment. Fiona Fox, who directs the Science Media Centre and Tom Field from the BBC.

538
01:02:44,010 --> 01:02:47,430
So look out for that one. Sally, many thanks again.

539
01:02:47,430 --> 01:02:53,340
Many thanks to the audience for all your questions and have a good evening afternoon wherever you are.

540
01:02:53,340 --> 01:02:55,054
Thanks. Thanks to all of you.