Cause area report: Antimicrobial Resistance

By Akhil @ 2023-06-06T08:35 (+199)

This post is a summary of some of my work as a field strategy consultant at Schmidt Futures' Act 2 program, where I spoke with over a hundred experts and did a deep dive into antimicrobial resistance to find impactful investment opportunities within the cause area. The full report can be accessed here.

AMR is a global health priority

Antimicrobials, the medicines we use to fight  infections, have played a foundational role in improving the length and quality of human life since penicillin and other antimicrobials were first developed in the early and mid 20th century.

Antimicrobial resistance, or AMR, occurs when bacteria, viruses, fungi, and parasites evolve resistance to antimicrobials. As a result, antimicrobial medicine such as antibiotics and antifungals become ineffective and unable to fight infections in the body. 

AMR is responsible for millions of deaths each year, more than HIV or malaria (ARC 2022). The AMR Visualisation Tool, produced by Oxford University and IHME, visualises IHME data which finds that 1.27 million deaths per year are attributable to bacterial resistance and 4.95 million deaths per year are associated with bacterial resistance, as shown below.

Figure 1: Composition of global bacterial infection related deaths, from AMR Visualisation Tool

This burden does not include that of non-bacterial infections, such as fungi or pathogens, which might increase this burden by several factors. For instance, every year, there are 150 million cases of severe fungal infections, which result in 1.7 million deaths annually (Kainz et al 2020). Unlike for bacterial infections, we do not have good estimates of how many of those are associated or attributable to resistance.

Concerningly, AMR is  escalating at an increasing rate (USA data, Swiss data, Mhondoro et al 2019, Indian Council of Medical Research 2021). One prominent report estimates that AMR will result in 10 million deaths every year by 2050 (Jim O’Neill report, 2014).

Even more concerningly, we may be at a critical juncture, where if we do not drastically change our current trajectory, we could run out of effective antimicrobials. This would mean that our ability to perform surgery, give cancer patients chemotherapy, or manage chronic diseases like cystic fibrosis and asthma, all of which hinge on the effectiveness of antimicrobials, would be significantly impacted. The very foundations of modern medicine could be threatened; the WHO has warned that we could return to a pre-antibiotic age, which would result in the average human life expectancy going down from 70 to 50 (WHO, 2015).

Beyond the health effects, there is a profound economic cost to AMR – for patients, healthcare systems and the economy. In the USA, the CDC estimates that the cost of AMR is $55 billion every year (Dadgostar 2019). Studies show that as a result of AMR,  the annual global GDP could decrease by 1% and there would be a 5-7% loss in low and middle income countries by 2050 (Dadgostar 2019). In conjunction, the World Bank states that AMR might limit gains in poverty reduction, push more people into extreme poverty and have significant labour market effects.

The importance of AMR is recognised by major governments and multilateral organisations. The WHO calls AMR one of the greatest public health threats facing humanity, the UK government lists AMR on its National Risk Register, and both GAVI and the United Nations Foundation term AMR as a ‘silent pandemic’. 

AMR is a neglected field 

Although there has been some global response to AMR, it has not been proportional  to its threat to healthcare systems and the economy. Despite many governments developing National Action Plans (NAPs)  in response to the WHO call for the same in 2015, and several public and private organisations, especially CARB-X and Wellcome Trust, making significant investments in the space (see the Global AMR R&D Hub for details on this), it seems unlikely that current investment will be sufficient to curb the rise of AMR.

There are several overarching reasons for this:

1.  Various solutions that have the potential to reduce the threat of AMR are either public goods or suffer from market failures that mean that they are currently not economically viable- it is because of this that R&D pipelines for new diagnostics and therapeutics to address AMR have dried up. 
2.  Secondly, there are inequities in global focus and funding on AMR- for instance, although many countries have established NAPs to address AMR, many resource constrained countries struggle to fund and implement their plans.
3. There are also competing interests and  conflicts of interest between different stakeholders (.e. between stewardship and access in the community, between agricultural productivity and inappropriate use of antibiotics) that constrain impact
4.  Finally, although there is a committed body of organisations and individuals working on AMR, work is often siloed and the infrastructure that they operate within is sclerotic. 

There are tractable interventions to reduce the burden of AMR

There are a number of uniquely and highly impactful opportunities to significantly reduce the burden of AMR that are untapped by the current funding landscape. 

AMR is a complex scientific phenomenon, and is driven by the use and overuse of antimicrobials in the human, animal and environmental sector. To provide a very brief overview into the types of interventions within the field, below is a simple systems maps of the drivers of AMR and the broad solution architecture:

Figure 2: Systems map of drivers of AMR and how it can be managed; Human drivers include poor sanitation and hygiene, lack of access to clean water and vaccinations, overuse of antibiotics, and lack of stewardship for responsible use of antibiotics. Animal health drivers include the overuse of antibiotics in intensive factory farming, and environmental drivers can include the overuse of antibiotics from  pharmaceutical manufacturing and hospital systems.

As part of my work for Schmidt Futures, I specifically sought to identify opportunities where additional work might have ‘big if true’ implications, as well as interventions and areas that are currently being overlooked or are neglected by current actors

In my report, which you can read here, I offer some  recommendations for important actions that can be taken to reduce the burden of AMR. 

You can get involved

Fund impactful work on AMR

If any of the recommendations or broader work in this report are of interest, I would invite you to get in touch at akhil@amrfundingcircle.com. 

Further, if you have an interest in offering ongoing support to  impactful work in the AMR space, I have recently launched the AMR Funding Circle, which aims to identify, vet and prioritize different projects and organizations working on AMR for funders and grantmakers.  In the process, the funding circle aims to support impactful work in the area, and to help coordinate the field at large.

  It will bring together funders who commit to one hour a month for a meeting, plus about an hour outside of the meeting to consider opportunities. To join the network there is also a $50,000 per year minimum expected contribution to the cause area of AMR.

If you are interested in being involved in the AMR Funding Circle, please also get in touch with me at akhil@amrfundingcircle.com
 

Found a charity

Charity Entrepreneurship (where I previously worked) did a round of research on health security, and amongst some other great ideas for new charities in the space, have recommended a charity that helps prevent the growth of antimicrobial resistance by advocating for better (pull) funding mechanisms to drive R&D and responsible use of new antibiotics.  If you are interested in this, please feel free to reach out to me or to the CE team directly!