One World, One Health – Tackling the Superbug Challenge
Bacterial culture prepared for testing new antibiotic candidates.

Humans, animals, plants and the environment we all share face escalating risks from antimicrobial resistance (AMR), with the potential for irreversible damage ever more likely. Both our health and the health of the planet are at stake, says a leading champion for more action.

We know what to do. One Health thinking has been with us for as long as the European Health Forum Gastein, which celebrated its 25th anniversary at last week’s annual meeting. But the COVID-19 pandemic has loudly proclaimed this to be an even greater imperative by underlining the interplay between human behaviour, public health and economic development as never before. What’s required now is for the global community to put health – human, animal and environmental – at the core of policy-making.

The G7 summit in Elmau a few months ago recognised this imperative with a commitment “to work in partnership to strengthen health systems worldwide and step up our efforts in pandemic prevention, preparedness and response under the One Health approach”. The G7 leaders included AMR in their final communiqué, promising to “spare no efforts to continue addressing this silent pandemic.”

A threat with more deadly potential than COVID-19

As the United Kingdom’s Special Envoy on AMR, I see it as my duty to educate the world about this threat that we all face from the increasing prevalence of drug-resistant microbes – including bacteria, viruses and parasites.

This is a pandemic which has the potential to be more deadly than COVID-19. It is already associated with five million deaths a year, making AMR the third-leading underlying cause of death globally. According to a ground-breaking study in The Lancet, published in January, drug-resistant bacteria alone were responsible for some 1.27 million deaths in 2019.

Meanwhile, a landmark O’Neill Review study has predicted that the death toll from AMR could reach 10 million each year by 2050 – if we don’t change the trajectory of drug resistance now.

Disproportionately affects the most vulnerable

Tragically, AMR disproportionately impacts the most vulnerable in our world, with much of the burden of AMR deaths occurring in sub-Saharan Africa where access to antibiotics and drugs is generally more constrained as is the laboratory capacity to detect drug-resistant microbes.

Lives and livelihoods are at stake, with the World Bank estimating that as many as 24 million more people could be forced into extreme poverty unless we collectively intervene.

Without antibiotics, I’ve said (with English understatement), “we would be in a really dreadful mess” or, more bluntly, “a post-antibiotic apocalypse”. Animals would die, plants would die and so would we humans in rising numbers, as our ability to produce food for the world’s growing population stalls. 

This is not some sci-fi scenario gorily filmed by Ridley Scott, but a clear and present danger to us all. So, the time to act is overdue. Because, as one colleague has put it: “The superbugs are beating us at a competition we can’t afford to lose.”

Fixing market failures

Antibiotics being distributed at a pharmacy in India.

There are hurdles to be overcome but they are not insuperable with sufficient public health leadership and political will. 

First and foremost, we need to fix a profound and protracted market failure. There has been no new class of antibiotics discovered in four decades. Chillingly, the World Health Organization (WHO) has identified that the clinical pipeline of antibiotics is insufficient to address resistance because so few drugs in development are truly innovative, or address the most dangerous classes of pathogens. 

A lack of incentives means that, unfortunately, the small start-ups that are the engines behind innovations can easily fall at the last hurdle or simply go bust – so new antibiotic discoveries never reach the patients who need them most.

We must redouble our efforts to find solutions that draw companies back to antibiotic development. The AMR Action Fund, which emerged from conversations between the WHO, Wellcome Trust and the pharmaceutical industry, is now backed by $1 billion in investment capital from some of the world’s biggest pharmaceutical companies. Designated for small and medium biotech firms with promising innovations, the Fund aims to stimulate the development of two to four new antibiotics by 2030. This is a great start. Now, we need more than this promising initiative.

More ‘pull’ incentives

The G7 has also committed to exploring ‘pull’ incentives to enable new antibiotics to come to market, and ensure that they are accessible to those who need them most, whilst guaranteeing responsible and appropriate use.

I am proud that England has led the way with its pilot scheme involving a subscription payment model for new antibiotics, with robust stewardship requirements. Following this model, the UK Government will start paying drug companies a fixed fee for supplying antibiotics. This will help tackle the growing global crisis over resistance to drugs and ensure that the treatments are accessible to patients enrolled in the National Health Service. A similar model could be adopted in the US in the form of the Pasteur Act before Congress which also offers upfront funding of up to $3 billion.

One Health and AMR

Inspecting a pig’s health in Busia in western Kenya.

Of course, the scope of fighting AMR in the One Health context involves many interventions across a range of sectors.

It involves steps to foster more rational, appropriate use of existing drugs for both human and animal health. It also involves the need to prevent zoonotic diseases from leaping the human-animal barrier as a result of ecosystem degradation and poor food safety practices. Similarly, more prudent use of antibiotics and other drugs is critical in the plant health and animal health sector, alongside that of human health. 

And at the same time, One Health thinking goes way beyond AMR to include the ways we foster healthier, more sustainable development that prevents disease from ever occurring While the term has been with us for two decades or more, One Health concepts have yet to be fully integrated into public health policy-making, as experience with the COVID pandemic and earlier outbreaks such as Ebola has underlined.

Last year, I convened The Trinity Challenge, bringing together the private sector and academia, united by the common aim of developing insights and actions to contribute to a world better protected from global health emergencies.

Over 340 applicants from over 60 countries shared their creative ideas, and I am proud that the winning solution, the Participatory One Health Disease Detection (PODD) from OpenDream in Thailand, empowers farmers to identify and report zoonotic diseases that could potentially pass from animals to humans, triggering another pandemic. Hopefully, we will see more approaches like this in the future.

To close the gaps in prevention, preparedness and response, we need a sustained exit from silo thinking and collaboration across countries and sectors. One Health thinking must come with One World policy-making that treats issues such as global food security, animal well-being and environmental sustainability as one paramount priority. We are, truly, all in this together.

Dame Sally Davies
Dame Sally Davies

Dame Sally Davies was appointed as the UK Government’s Special Envoy on AMR in 2019. She is also the 40th Master of Trinity College, Cambridge University. She was the Chief Medical Officer for England and Senior Medical Advisor to the UK Government from 2011-2019. She served as a member of the World Health Organisation (WHO) Executive Board from 2014-2016, and as co-convener of the United Nations Inter-Agency Co-ordination Group (IACG) on Antimicrobial Resistance (AMR), reporting in 2019. In 2020, Dame Sally was announced as a member of the new UN Global Leaders Group on AMR, serving alongside prominent figures from around the world to advocate for action on AMR. In 2020, Dame Sally became the second woman (and the first outside the Royal family) to be appointed Dame Grand Cross of the Order of the Bath (GCB) for services to public health and research, having received her DBE in 2009.


Image Credits: WHO, AMR Industry Alliance, ILRI / Charlie Pye-Smith.

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