Tim Evans is the senior director of health, nutrition and population at the World Bank Group, an international financial institution that provides loans to developing countries for capital programmes. From 2010 to 2013, he was dean of the James P Grant School of Public Health at BRAC University in Dhaka, Bangladesh, and senior adviser to the BRAC Health, Nutrition and Population Programme. From 2003 to 2010, he was assistant director-general at the World Health Organization (WHO). Before this, Evans served as director of the Health Equity Theme at the Rockefeller Foundation. Earlier in his career, he was an attending physician of internal medicine at Brigham and Women’s Hospital and assistant professor in International Health Economics at the Harvard School of Public Health, both in Boston, Massachusetts. He is a board member of several international health alliances.
Evans has been at the forefront of advancing global health equity and strengthening health systems delivery for more than 20 years, and has been a co-founder of many partnerships, including the Global Alliance on Vaccines and Immunization (GAVI), as well as efforts to increase access to HIV treatment for mothers.
The World Bank report ‘Drug resistant infections: a threat to our economic future’ (published in September 2016) warns that antimicrobial resistance could be a global public health catastrophe if the world fails to act. How serious a threat is this?
It’s an extremely serious threat. We already have major problems with antimicrobial resistance (AMR) if we look at diseases such as malaria, tuberculosis and HIV. But now we also have antibiotics that have diminished effectiveness against infections such as gonorrhoea. What this would mean in terms of costs of inaction by 2050 is really concerning. Our report builds on a review by Lord Jim O’Neill, which suggested the costs of inaction by 2050 would be somewhere around US$100 trillion if nothing is done. What we have done is to look at why this matters with respect to the constituencies that are most important to the World Bank, which are low-income and middle-income countries, and what we find is that they would bear a bigger proportion of the burden by 2050.
The study findings of low and high antimicrobial resistance scenarios conclude that healthcare costs would range between US$300bn and US$1 trillion per year by 2050. Which would be the biggest problem areas?
The costs of dealing with high levels of AMR and the challenges of treating people with infections that are resistant to a broad range of antibiotics are the biggest problem areas. This relates to longer hospital stays, many more health complications and the costs associated with treating them. It’s managing a much larger volume of patients who will have infections that are not amendable to the cost-effective treatments we have now.
The report also mentions there are challenges for low-income and middle-income countries to fund research and development for new medicines. How can these countries tackle these challenges?
There are many ways forward, but the best way is to make smart investments to preserve the effectiveness of existing medicines. We have evidence that things can be done to strengthen the improved use of antibiotics in existing healthcare systems; universal access to vaccinations, for example. We have an effective vaccine for pneumococcal infection, as well as for haemophilus influenza b. And if we can have 100% coverage of children with these vaccines, that’s going to decrease the need for antibiotics to treat those infections because they will be prevented. That reinforces our work, for example, with GAVI — making sure all children have access to the vaccines they need.
The pipeline of new drugs, vaccines and diagnostics also needs support and these are issues that our report did not go into detail on. We have gained a lot of experience over the past 20 years on how to manage the need for appropriate incentives, and various mechanisms to try to accelerate and strengthen the pipeline for new types of products that the market will not deliver on its own.
The report concluded that antimicrobial resistance might impact on new drugs if they lose their effectiveness too fast and therefore investments in developing such drugs could be squandered. How can this be averted?
We have to look into developing our system for more effective and rational use of antibiotics. For example, it’s been made absolutely clear that we need to develop mechanisms to decrease the use of antibiotics in animal husbandry, where they’re being used as growth promoters. If we do nothing to address that, then we will be creating an environment that will risk favouring the development of superbugs.
However, in the context of the healthcare system, we also need to look at ways to strengthen rational use. We have some very good examples to build on. We know that essential laboratory capacity is missing in many countries, so we should be investing in essential laboratories as we have in, for example, east Africa through the East Africa Public Health Laboratory Networking Project. On top of that US$190m investment across five countries, we also invested US$160,000 to fund an AMR capacity in Kenya to allow it to monitor AMR more effectively.
These sorts of investments make a big difference in providing countries with the capacity to understand the situation, the extent to which they have a problem, and the extent to which they’re managing that problem effectively.
Your analysis of antimicrobial resistance containment measures for 139 countries shows that if US$9bn was spent annually between 2017 and 2050, the cumulative global benefits would be between US$10 trillion and US$27 trillion, respectively. Is this feasible and achievable?
We think it is. Across 139 countries this is a small amount per annum, especially if you look at it as the percentage of the total invested either in health or the health and agricultural sectors, where the primary investments would be. Then if you look at returns on investments, with respect to the cost of inaction, that represents a small fraction — around 0.5% of the cost on inaction. So, it’s a massively high yielding return on investments.
In the conclusions, the report states that the largest risks are a failure of prioritisation of antimicrobial resistance containment and potentially inadequate funding for public health systems. Can you put this into context?
The ability and likelihood of public health systems in making sure their public health investments are secured is an area in which every country could improve. So this means it is not only related to AMR but also related to outbreaks of infections such as Ebola. There is a need for the global health community to be far more vigilant that these investments are being made. We have a lot to learn from the past, but in the present we’re in a good situation. There has been a tremendous amount of goodwill and mobilisation about learning the lessons from the Ebola crisis. We’re beginning to see across all institutions, including the World Bank, a greater focus on the sorts of investments that are necessary to secure those core veterinary and public health functions that will largely mitigate and contain AMR.
Apart from the laboratory investments in east Africa, what else is the World Bank doing to contain antimicrobial resistance?
We’re doing something similar in West Africa to build a network of public health laboratories. But I’ll give you two more examples. One is in the context of our efforts to strengthen health systems towards achieving universal health coverage. We’re doing our best to ensure there’s universal childhood immunisation because those vaccines will make a huge difference with antibiotic use over time, not just in one country but across all countries. A second example relates to the World Bank Group’s Fund for the poorest, called IDA (International Development Association). In our next round of IDA, beginning on 1 July 2017, we will discuss the investment in these core public health functions across low-income countries, which are covered by the IDA Fund.