Excellencies,
Distinguished participants,
It is my great honor to share my thoughts as a keynote speaker for this
conference, "Universal Health Coverage in an era of Antimicrobial Resistance
and Pandemics" with such distinguished guests and participants mainly from
ASEAN, Europe and Japan.
I would like to thank Asia-Europe Foundation, AMR Clinical Reference Centre,
and the Ministry of Foreign Affairs of Japan for organizing this meaningful
conference.
As you all know, UHC has been the most important pillar of Japanese health
diplomacy under the human security philosophy in the past few decades. To
attain UHC in low- and middle-income countries, we have been working on
each of its elements: ensuring access to medical products, investing in
information systems, fostering the health workforce, strengthening health
financing, expanding service delivery, and establishing governance.
While Japan continues to commit to attaining UHC as part of the 2030 SDG
goals, COVID-19 taught us an important lesson: UHC is not just for peacetime,
it is vital for health emergencies. Building a resilient health system to attain
UHC is a pre-requisite for us to prevent, prepare and respond to the pandemic
and AMR.
During the pandemic, demands for health care surged. It was not easy for any
country to meet all demands. But countries with resilient health systems and
greater UHC coverage coped better with these surges, thus minimizing the
excess mortality and social restriction.
This inter-connectedness between UHC and the pandemic is reciprocal.
Preventing, preparing, and responding to the next pandemic is vital for us to
maintain UHC. Globally, during the past three years of the ongoing pandemic,
we have experienced 15 to 20 million excess deaths. Some of them are due
to infection caused by COVID-19, but much of this excess mortality was due
to the disruption and malfunction of UHC systems. For example, in many parts
of the world, we were not able to maintain routine immunization or could not
provide timely cancer treatment. We can see therefore that pandemic
preparedness is essential to maintain the smooth functioning of UHC systems.
Therefore, the Japanese government's strategy on global health diplomacy,
revised last year, set out two inter-connected objectives: strengthening
pandemic PPR (Prevention, Preparedness, and Response) and attaining UHC.
With full support of this revised strategy, I have one concern: AMR is still
under-recognized.
Just as UHC and the pandemic are inter-connected, which we all learned from
our experience during COVID-19, we cannot attain UHC without addressing
AMR, and we cannot address AMR without attaining UHC.
Antibiotics are often referred to as one of the top ten greatest inventions in
human history, together with the wheel, the compass, the printing press, the
internet, etc. It is not just for curing your pneumonia, but it is a prerequisite
for us to deliver modern medicine, including surgery and cancer chemotherapy.
As we all know, we are gradually losing the efficacy of the existing antibiotics
while we have been facing an urgent situation with rapidly shrinking
development pipelines for the new ones. The disease burden caused by AMR
is already enormous: An analysis published in the Lancet last year estimated
that in 2019, nearly 5 million people died from illness in which bacterial AMR
played a part, of which 1.27 million deaths were the direct result of AMR,
meaning that drug-resistant infections killed more than HIV/AIDS (864,000
deaths) or malaria (643,000 deaths). It is unthinkable for us to bear this
huge and growing burden while attaining UHC.
The converse is also true: without attaining UHC, we cannot control AMR. In
many parts of the world, people do not have access to qualified health
professionals, hence buying antibiotics – some of which are often substandard
and falsified – on the street without professional advice whenever they get a
fever. Many health facilities do not have access to safe water and sanitation,
which makes it very challenging to control infection. All these sub-optimal
health systems contribute to AMR becoming more serious.
Today's symposium is very timely as we are gathering lessons from the ongoing
pandemic and renewing our common understanding of the inter-linkage between
UHC, AMR, and pandemics.
Then, I would like to talk about what we should do in the coming years on AMR.
Actually, AMR is not a new agenda. It was first mentioned as early as 1945 in
the Nobel Prize award speech by Dr. Alexander Fleming, who found the first
antibiotic, penicillin. Since then, as Dr. Fleming predicted, the situation
gradually worsened, and it was only in the last ten years that it started to
receive political attention as a serious global agenda.
The turning point was 2014 to15 when world political leaders at that time –
UK Prime Minster Cameron, US President Obama, and German Chancellor Merkel
– identified AMR as a grave concern for the first time. This facilitated the
cascade of both political and technical commitments in the following years,
where I myself had the privilege of participating as the Health Minister.
In 2015, WHO World Health Assembly adopted the Global Action Plan on AMR
and urged member states to develop National Action Plans within two years
with the One Health approach: the health of humans, animals and the
environment.
In the G7 arena, the 2015 Elmau Summit addressed AMR for the first time in
its history, followed by the Ise-Shima Summit in 2016, when I as Health Minister
chose AMR as one of the three biggest health agendas.
The cascade continued in 2016: the first UN General Assembly High-Level
Meeting on AMR was convened with its political declaration and established
Inter-Agency Coordination Group (IACG), which later evolved into the Global
Leaders Group (GLG) on AMR in November of 2020.
But In spite of these series of commitments, the challenges we are facing
remain dire. Five strategic objectives are identified in the Global Action Plan
adopted in 2015, but we are still struggling with limited progress. Let us briefly
touch on each of these five issues.
Firstly, "awareness":
Unlike the issue of climate change, public awareness of AMR around the globe
is still very low. How many of us are conscious to buy antibiotic-free meat,
compared to the growing number of people look for the carbon footprint of the
goods they buy? Without knowing the issue, we cannot make a difference.
Secondly, "surveillance":
Without globally integrated surveillance systems, we critically lack standardized
data collection and reporting systems on antimicrobials regarding humans,
animals, plants and the environment.
Third, "better hygiene":
Clean water and sanitation are still big global agendas.
Fourth, "stewardship":
We should not overlook the fact that misuse and overuse of antibiotics on
humans, animals, and plants are still prevailing. In addition, buying antibiotics
without a prescription can still be observed in many parts of the world.
Fifth, "Research and Development":
Johnson & Johnson quite recently announced its withdrawal from R&D of new
antibiotics. The reason is obvious. Many pharmaceutical companies ceased to
work on antibiotics, and only a handful remain. As a result, the clinical pipelines
of new antimicrobials are very few. We are losing the efficacy of the existing
antibiotics day by day, while there is little replacement. So, this is one of
the most pressing policy areas to which global leaders including G7
President Japan must respond by quickly introducing effective push and pull
incentives for the development of novel antimicrobials.
Although, we have made a lot of progress in the past ten years, we are still
struggling with the very basics of the objective we jointly committed to in 2015.
And we cannot afford to lose this battle because the matter is not just treating
our pneumonia, but at stake is our civilization.
Now, the scope of the AMR becomes even wider.
Two weeks ago, I attended the 6th GLG meeting in Barbados, for the first time
in person, where we discussed a wide range of key issues, including financing,
the role of the private sector, environment, R&D, surveillance, and animal health.
GLG's quadripartite joint secretariat comprised the WHO, FAO, UNEP(UN
Environment Program) and WOAH (World Organization for Animal Health) are
quite instrumental in moving forward the global movement of AMR.
It is important to note the composition of the joint secretariat. It literally
represents the One Health concept, which recognizes that the health of humans,
animals, plants and the environment are closely linked and interdependent.
On the first day of this GLG meeting, UNEP launched a report "Bracing for
Superbugs" for this meeting. This report urges that curtailing pollution created
by the pharmaceutical, agricultural and healthcare sectors is essential to
reduce the emergence of AMR.
In our discussion at the GLG meeting, the chair, Prime Minister of Barbados Mia
Amor Mottley summarized that:
"The environmental crisis of our time is also one of human rights and geopolitics
– this UNEP report on AMR is yet another example of inequity, in that the AMR
crisis is disproportionately affecting countries in the Global South."
I fully agree with our colleague PM Mottley's assessment. AMR could merely
mean a health agenda, but for many parts of the world, this is also an issue of
the North-South divide. It affects Low- and Middle-income countries much
more, but we also have to note that there is no national boundary for infectious
diseases. As the proverb says, "a chain is only as strong as its weakest link".
Once an outbreak occurs somewhere, it comes to everybody as we experienced
with COVID-19.
In this meeting, GLG members discussed the need for integrated surveillance
and monitoring with globally standardized data, strengthening of laboratory
capacity, and coordinated sound governance.
Now, you notice that this is exactly the same as the basic strategy for UHC and
PPR. UHC, PPR and AMR are inter-connected. Hence AMR needs to be
discussed equally with other pandemic threats at the ongoing negotiation of
the WHO instrument on pandemic PPR. AMR is not a "slow pandemic" or "silent
pandemic" anymore. It could be a real pandemic at any time.
In order to solve a market failure effectively, we do need a proper and timely
public intervention of some sort from governments. Since AMR is a case of
market failure, we must come up with the right set of policies to overcome the
challenges from AMR.
Regarding National Action Plans, about 170 countries now have their own plans
on AMR. But only some 20% of countries have viable budget lines for financing,
which explains why the pace of the global fight against AMR is so slow.
There lies a crucially important root cause of the slow pace of our global fight
against AMR both in high-income countries and low- and middle-income
countries, coupled with the low global awareness of the importance of AMR.
Budget allocation is nothing but a domestic political process. Low-income
countries always face immediate financing problems due to the lack of financial
capacity, but behind the financing always lies the political conflict concerning
economic growth versus health.
"The Muscat Ministerial Manifesto on AMR" of last November includes ambitious
commitments such as "reduction of the total amount of antimicrobials used in
the agri-food system by at least 30-50% from the current level by 2030".
But, as some of the high-income countries, including Japan and the US declined
to commit, domestic politics for economic growth and profit often dominate over
people's health.
Thus, GLG came to the conclusion that for the implementation of National Action
Plans, domestic and international financing and public-private partnerships are
the three main sources of financing the fight against AMR but there must be
some kind of mechanism that could help overcome domestic political battles
concerning economic growth and health.
Also, we have to recognize that even in high-income countries, there are not
enough numerical targets set on relevant indicators. Root causes of it are
again, the conflict with regard to economic growth, profit, and health.
It is always true that it costs less if we prepare well, which we all painfully
learned from COVID-19. And we could not afford to avoid the discussion to
fundamentally overcome the challenges of AMR. We have to invest, finance,
and achieve our goals.
We have a window of opportunity towards the UNGA High-level Meeting on AMR
in 2024. But the window is not always open. I would also like the Indian G20
process to work on AMR, and coordinated commitment by G7 and G20 would
pave the way toward a world without AMR challenges.