NCDs, AMR, and Policy Crossroads

Interactive Transcript

spk_0 So these things of NCDs and MR are inextricably linked and actually what we need is the NCD

spk_0 community to stand up and say sort out MR or we're going to die of infection.

spk_0 It is one of these issues that really needs loud voices just to make sure that we are

spk_0 heard and it moves from the sort of technical area where people have known about this for a long time

spk_0 into the political sphere where it luckily is right now.

spk_0 Everything in health is connected.

spk_0 While the work of science is often to pull things apart and dissect them for better understanding,

spk_0 we also have to put things together to see the relations between things and of course to view the bigger picture.

spk_0 This is the second episode in a short series of cross-cutting conversations covering chronic diseases or NCDs

spk_0 along with environment, aging, antimicrobial resistance and other health topics.

spk_0 We'll discuss co-benefits, common policy challenges and the value of acting collectively.

spk_0 My name is Mavney Oloon and this is Health in Europe.

spk_0 In this conversation I am joined by Professor Dame Sally Davies, former Chief Medical Officer for England

spk_0 and Member of WHO's Executive Board and current UK Special Envoy on antimicrobial resistance

spk_0 and by Danilo Lofowong, WHO Europe's Program Manager for antimicrobial resistance.

spk_0 Do you first, Sally, just to set the scene for listeners who may not have previously linked the challenges of non-communicable diseases

spk_0 and antimicrobial resistance or AMOIR, can you very briefly describe some of the overlap as it pertains to the real lives of patients and to health care services?

spk_0 Well, let's take cancer as one of the classic chronic diseases and all of us have family or friends who've had cancer.

spk_0 And I'll tell you my own story. I had bowel cancer that was picked up by colonoscopy screening in January.

spk_0 I had an operation and I'll go to the very end of the story, it's all out, I'm cured.

spk_0 But back to the operation, five days out after the operation I had been expecting to go home and I had a very high temperature.

spk_0 You know that one in five cancer patients undergoing treatment are hospitalized because of infection and antibiotics save their lives when they work.

spk_0 There I was at four in the morning with this very high temperature and what did my husband say? He said, oh my God, you've got an infection.

spk_0 I hope it's not AMOIR, I don't want you to die because people are dying with cancer but not of the cancer of untreatable infections.

spk_0 And actually there's new data out in the Lancet from the US in many hospital outpatients and on the cancer wards.

spk_0 And there is evidence that AMOIR is even more prevalent or frequent in the wards where the cancer patients looked after the other wards.

spk_0 So not only do they get more do we get more infections but were exposed more to AMOIR.

spk_0 And going back a couple of years we surveyed oncologists in the UK and 95% that means the overwhelming majority worried about the impact of superbugs on the future of cancer treatments and almost half worried that it would make chemotherapy on viable.

spk_0 So that as an example tells you that if you've got a chronic disease, you're more prone to infection, you're more therefore you're at risk and some patients even more at risk because of the superbugs being around and you may die of that.

spk_0 So these things of NCDs and AMOIR are inextricably linked and actually what we need is the NCD community to stand up and say sought out AMOIR or we're going to die of infection.

spk_0 Thanks Sally and I'm so sorry you've been through all of that recently.

spk_0 It's very illustrative of the very real risks posed by these infections that we are finding increasingly difficult to treat both in healthy people undergoing surgery but particularly in people whose immune systems are already compromised on a kind of getting treatment for diseases such as cancer.

spk_0 AMOIR has been termed the silent pandemic and equally cases of NCDs have been referred to as invisible numbers referring to the lack of urgency given to preventing what is in fact preventable.

spk_0 So how can we make visible the invisible.

spk_0 So I did used to think AMOIR being called the silent pandemic might wake people up but I'm not a fan of it any longer.

spk_0 It didn't work, people didn't sit up, it was too silent and you have to have the numbers.

spk_0 And so the global burden of disease published in the Lancet some very interesting data.

spk_0 1.14 million directly dying in 2021 of AMOIR as well as looking at the demographics.

spk_0 Disincreased by more than 80% of AMOIR in the over 70s between 1990 and 2021.

spk_0 So you can see that it's serious.

spk_0 We've even funded economic studies to look at the economic impact.

spk_0 There is a silver lining to this data that actually interventions globally wash,

spk_0 that's clean water and vaccinations have had a very good impact on reducing child mortality from infection and therefore AMR.

spk_0 But we've got to talk to policymakers in language they understand and that takes us back to the economic studies and the return on investments.

spk_0 One study we funded the global human care cost due to AMR could rise to 150 billion a year by the end of this century.

spk_0 39 million people will have died of AMR.

spk_0 So you know we have to wake them up to the reality.

spk_0 We need to show them that investing in AMR for every pound or dollar invested you get a return of $24.

spk_0 That's a fantastic value.

spk_0 In development of new antibiotics could save more than 10 million lives over the next 25 years.

spk_0 And if you put new antibiotics together with improved healthcare, vaccination, safe water, sanitation in the low income countries,

spk_0 we could save 110 million lives and there'll be young lives, productive lives impacting their economies.

spk_0 And then if you remember this is a one health issue, look at the global impact of AMR on livestock.

spk_0 If we don't take action then we will reduce global GDP by around 40 billion, 40 billion dollars a year.

spk_0 So you know we really need to move it.

spk_0 But I have found the personal stories really change things.

spk_0 And so sadly, about two and a half years ago my own Goddaughter died of AMR.

spk_0 And as I tell politicians that they say is that why you came into it?

spk_0 And I say no, if you want me to tell you stories of my own patients and I can, it's really sad.

spk_0 But we also need to move beyond the ministries of health and the environment and agriculture into the finance ministries.

spk_0 And we really work very hard at that in Britain.

spk_0 Thanks Sally and thanks for sharing that.

spk_0 Danilo from a communications perspective, we're working against numbers fatigue and often a seeming competition between diseases.

spk_0 All the while trying to present a coherent picture of what we're at in terms of public health.

spk_0 Without completely overwhelming people, this isn't an easy task.

spk_0 Sally's of course absolutely right that these numbers are really needed and they're well, they needed to compel and convince policymakers, decision makers and politicians.

spk_0 People probably respond better to sort of relative numbers.

spk_0 This is equivalent to the economy of these number of countries or just trying to put things into perspective that related people.

spk_0 And relating to people is really important as Sally also mentioned that bringing stories and anecdotes brings it closer to people.

spk_0 There's numbers and technical terms.

spk_0 We've seen that doesn't really rally people, doesn't get them off their chair.

spk_0 But if a loved one or if they themselves are exposed to an infection that just is very difficult to treat, if at all.

spk_0 That's when people start realizing that well this is a thing that's here, it's not something from the future, it's not something we only see on television or read in the papers.

spk_0 This is a real thing.

spk_0 The other thing of course is also that even though we always say that AMR is a complex issue and it requires multiple sectors and disciplines, we still treat it as a single issue.

spk_0 I always say there's always something for everybody in AMR.

spk_0 But right now there's a very big link to AMR in conflict, AMR disasters.

spk_0 And other things that are occupying the news, the politicians and the people.

spk_0 I'm also very happy with this conversation linking it to non-communicable diseases as where WHO recently launched these quick buys with some results within five years.

spk_0 And I think this is an idea that we could use in AMR as well.

spk_0 Sally, you've worked very closely with politicians.

spk_0 Now it's often pointed out to us academics that public health interventions such as those needed to tackle the relentless rise in NCDs and intro-resistant infections.

spk_0 That our interventions simply aren't amenable to short political cycles.

spk_0 So maybe this is a bit simplistic.

spk_0 But is there a case to be made for asking our policymakers to just do the right thing?

spk_0 And I'm using it in frittacamas as I asked this.

spk_0 We have to recognise realities.

spk_0 And I start from discussing with them the fact that I know they want to do good.

spk_0 That they're there to do a good job.

spk_0 And that they want to do the right thing and I'm going to help them.

spk_0 And so it is a question of trying to show them why they have to do things.

spk_0 And I think stories help. There's no doubt about it.

spk_0 But the values they usually will buy into where they find it difficult is putting lots of money, new money in when there is none at the moment anywhere.

spk_0 And they're not going to get any benefit from it.

spk_0 But even then, at the moment our government has got a big majority and they've classically this party been very supportive of public health.

spk_0 So they are helping and continuing forwards even in a very difficult economic situation.

spk_0 So not starting with here's the data you must.

spk_0 But I know you want to do good things.

spk_0 So it's a question of working together constructively.

spk_0 We can do it.

spk_0 Speaking of working together, the UN High Level Meeting on AMOIR took place in September of last year.

spk_0 What lessons learned can you share with the NCD community in terms of preparing for the upcoming high level meeting on NCDs in this rapidly changing and frankly deeply challenging political landscape?

spk_0 So high level meetings are terribly important.

spk_0 They bring the world together to negotiate about things that matter to everyone.

spk_0 But it's important not to overreach.

spk_0 And by overreaching, I mean not leave behind anyone.

spk_0 So it has to work for low income countries and high income countries.

spk_0 And overreaching is getting into too much detail.

spk_0 My academic friends wanted masses of targets in our high level meeting on AMOIR that they've made up.

spk_0 But Sally, they're right. They're right.

spk_0 I said, I don't know whether they're right or not. I haven't been into the evidence.

spk_0 But what I do know is we haven't bought into them as a global community.

spk_0 And new academics can't impose them.

spk_0 On the other hand, what you don't want is the lowest common denominator.

spk_0 We in Britain brought a lot of people together, a Wilton Park, a good year before the high level meeting.

spk_0 And thrashed out what were the common issues that we really had to push.

spk_0 And what became clear was that the developing world, the low middle income countries,

spk_0 what they wanted was to recognize you didn't get anywhere with AMR.

spk_0 If you weren't on top of preventing and treating infection, that takes you into wash.

spk_0 It takes you into vaccines.

spk_0 It takes you into access for antibiotics.

spk_0 So we started our outcome document by listening to that and saying, we've got to sort all of this.

spk_0 And then addressing AMR and moving it forwards.

spk_0 And I'm proud of how all the politicians from around the world came together to make a meaningful difference.

spk_0 This is such a complex and polarized world.

spk_0 And we're talking about one health, which for many people makes it almost untouchable.

spk_0 What do you mean? What do we do? How does this work?

spk_0 And we really, between all these countries, produced something that was worthwhile,

spk_0 we listened to the voices and priorities of the global south and we delivered in the outcome document on their needs

spk_0 and the leadership from Barbados and Malta as co-convenants.

spk_0 And ambassadors was wonderful.

spk_0 So of course, you had to recognize that if you didn't put the idea in at the beginning,

spk_0 it wasn't going to come out at the end.

spk_0 You couldn't shift things because this is diplomacy and it's diplomacy in New York style.

spk_0 I hope that for the NCD high level meeting, there's such good leaders in the co-convenants.

spk_0 But because they really make a difference, I met with them regularly in person or on Zoom.

spk_0 But you know, this is an intergovernmental negotiation.

spk_0 And that is quite different from what most people in health are used to.

spk_0 They used to talking to their own ministers, rather than the health ministers and generally not doing the negotiations.

spk_0 They may define the red lines, but they're not doing the negotiations.

spk_0 It's a foreign office, they're diplomats, and it has to fit with all the other bits of diplomacy going on.

spk_0 As is a multi-year process of building knowledge and understanding in New York across everyone.

spk_0 You're touching on so many different things there, Sally.

spk_0 The cross-sectoral nature of effective public health policy making, working with foreign affairs,

spk_0 economists, all of which has yet another complex dimension in terms of coordination and communication to our work.

spk_0 You also touched on this tension area, the science of the problem and the science of the solutions.

spk_0 You mentioned academics with their targets, which are based on the science of the problem.

spk_0 But as you know, we often need multiple other disciplines involved to develop solutions

spk_0 because they are social and political.

spk_0 Well, you're right. This is a political process by definition.

spk_0 It's therefore a social process because governments and negotiating all sorts of different things.

spk_0 And let me highlight also the first draft, which is called the zero draft,

spk_0 really does determine a lot of the directions.

spk_0 So you need to be in there through your diplomats working to make sure that zero draft is a good basis to work from.

spk_0 We have to hear all the academics, but one of the things I've been battling for since 2018, and Daniela Nosez is an independent scientific panel to look at the evidence.

spk_0 Because if you construct one, look at the IPCC effectively and it's independent, then they can be tasked with working out some of these complex issues rather than this group of academics who someone might hear have heard of and trust, but others might not or that group or they argue.

spk_0 I mean, we know that sound of advances are we're here? Oh, it's actually a bit more like that.

spk_0 Toe, it's no over here now until you get to consensus.

spk_0 And that can't play out in a political process or we lose everyone.

spk_0 So for us, I don't know that you could do that with the NCDs, have an independent panel. I'm not sure it's needed, but we need the recognition of listening to academics,

spk_0 but then putting it into this social and political process and moderating their asks.

spk_0 Daniela, what was your experience of that process and what are some of your takeaways that we in the NCD community can learn from?

spk_0 One of the driving forces behind that zero draft, I might add, and working very hard to progress it.

spk_0 I would like to add to what what Selim mentioned just now is that this political declaration that came out last year for AMR was not the first one.

spk_0 There was one in 2016, which us working in the area for a long, long time really saw as, okay, now we're there.

spk_0 This is the highest level of governance. Everybody agrees now things will happen and they didn't, at least not to the extent that we had hoped.

spk_0 And of course, we wanted to find out why is that and try to learn from the inaction that came out of that.

spk_0 And I think one of the things that came out is that the language of the political declaration was very aspirational, very high.

spk_0 We should be doing this and in that sense, one, it was not very innovative because we've known these things for many years.

spk_0 And second, it wasn't really assigning any duties to any particular group.

spk_0 So it was very unspecific.

spk_0 So what we've learned from the declaration that came out last year is that you have to be more action oriented.

spk_0 You have to describe, you have to assign some duties to institutions or put some responsibility in countries.

spk_0 And then finally, I think what was lacking and what maybe still lacking a little bit is a level of accountability.

spk_0 There is no consequence of inaction at the political level at least.

spk_0 I mean, people of course are suffering, but at the political level, not doing anything you can always hide behind, but there's so many other things that we need to do.

spk_0 And ultimately, there is no alternative but to work on antimicobro-resistance.

spk_0 The other thing more or less from a personal observation when I was there is that it was a great opportunity to see my friends and colleagues for many years.

spk_0 Working in AMR and we would meet each other at all these different side events and we were talking to the same people we were talking to the converted.

spk_0 And so my suggestion to the NCD community is to come out of your bubble and involve other areas, other disciplines that first of all you can learn from, but also that you need in a more comprehensive approach.

spk_0 So I think that's a lesson learned for AMR and hopefully lesson learned and acted upon for non-communicable diseases.

spk_0 We have discussed the role of academics and policy makers in researching and making commitments or legislating for public health.

spk_0 Can you both speak a little bit now about the role of NGOs or civil society organizations and the role of the general public?

spk_0 Public support, media support, are central to making anything happen. Politicians respond to that.

spk_0 So we've been trying all sorts of things.

spk_0 I work quite closely with a number of journalists and try and feed them stories if I see it.

spk_0 One example of bringing people in is our musical lifeline which started in Scotland with an NGO developing a musical around the life story of Fleming and taking it to the Edinburgh festival and it was a sell out.

spk_0 And it's developed and we're very much involved in trying to support and find money for it.

spk_0 And it's now that story entwined with a real life story of a young man who gets Balcansa just like I had Balcansa.

spk_0 The operation was a success but he did die of AMR and so it's heart-rending.

spk_0 And it's wonderfully moving because the chorus are community people.

spk_0 Their science teachers, researchers, infectious disease doctors, nurses and people.

spk_0 So they join the chorus and then at the end in one sentence they say what AMR means to them and it's so powerful.

spk_0 We took it to off-Broadway for the month of September last year and it was an amazing sell out.

spk_0 And I think one of the posts, I think it was a New York Post said it was the best way to get complex science over to the public.

spk_0 And the singers even sang on the floor of the General Assembly, the first singer since ABBA.

spk_0 We have one NGO that's wonderful, the British Society for Antimicrobial Chemotherapy, who run courses around the world who support parliamentarians to talk about AMR.

spk_0 So we try and work to bring people in in different ways but there's no doubt that we're doing this for the public and without the public being aware and calling for it we're not going to get to where we really need to be.

spk_0 And the last thing I'll mention is in 2020 I set up a charity called The Trinity Challenge and we run youth challenges in AMR in learn middle income countries.

spk_0 We've done two so far, a couple of hundred young people come together on Zoom, talk about AMR so they get an education and decide on what campaign they should run locally on what subject.

spk_0 And then we set them a competition to design a program, we give six prizes of six thousand pounds each and they run those campaigns locally.

spk_0 And that really, you know, getting youth in the next generation in learn middle income countries has a wonderful expanding cascade in pants.

spk_0 In terms of NGOs and civil societies, of course, extremely important.

spk_0 I always I'm very happy to work where I do is that we were in the morning I could visit a laboratory the afternoon I can talk to a hospital manager and in the evening I can talk to a minister.

spk_0 But I don't get to talk to the people on the street and this for this we need, you know, champions out there that are very passionate and can somehow translate our very high level messages into something that resonates to the people that they talk to that need to be convinced.

spk_0 And this is sort of a very natural extended arm of what it is that we're trying to do so there are indispensable absolutely also responding to what what's how you just said, I you're absolutely right strong focus on the next generation.

spk_0 Both of caretakers about also next generation of patients is really, really, really important and you you touched upon arts and health, which is another sort of under recognized area that that really need to to

spk_0 I don't want photographic arts and health is fantastic that you did and curated.

spk_0 Thanks. Thank you very much. And actually I was I was going to mention that the sort of the stories of AMR that's another way of of trying to get to to people when we made this this exhibition and thank you for acknowledging that Sally.

spk_0 And actually where we took stories from well anybody who had something to say about AMR I was not necessarily specific about AMR survivors or doctors or nurses could be midwives, restaurant owners advocates.

spk_0 Anybody who would want to share something was was welcome because of course the stories have to be have to cover broad scope to cover pretty much everybody's or to make sure we cover everybody's views on this.

spk_0 One of the very interesting emerging cross-cutting areas of research in public health is around commercial determinants of health or industries influence in the public health sphere.

spk_0 This could potentially be a strong unifying area for public health.

spk_0 So let me start. First of all, I don't call them commercial determinants. I call them commercial drivers. They are something we can do something about.

spk_0 Take tobacco, China and Japan still get a part on their tobacco industries, the governments do and they get a lot of tax.

spk_0 So they have not been as strong as Australia who led the way and Britain and other countries.

spk_0 To look at it from the AMR perspective working with the private sector, it goes pretty well.

spk_0 We all know there's a market failure for developing new antibiotics and new anti-infectives and we all want to try and address that and we are trying through the G7 to address it through pulling the centives.

spk_0 But I think the commercial drivers of NCDs are much clearer but it's not in the interest of those companies to take action because it will hit their bottom line, their profit and companies are set up to make a profit in general.

spk_0 When I talk to people and chief execs and people, what they say is we don't mind changing how we work on the drivers of obesity and things like that in dark.

spk_0 But we want a level playing field so you have to regulate because why should we, a chocolate maker or a supermarket do it and lose money when the other ones are not doing it.

spk_0 So that takes you straight into regulation. Wouldn't it be wonderful if we had more regulation and tobacco has led the way?

spk_0 Of course, one of the groups that we work with that can help our investors because if they're long-term investors, either universal owners or asset owners for the long term, they're interested not just in immediate profit but in also maintaining the health of society longer term.

spk_0 So they don't people like this invest in tobacco because you get a quick profit but you're going to pay like anything with chronic respiratory disease and cancers.

spk_0 And so we've been working with 23 investors for I think six years now to bring them in as supporters, understanding the issues about AMR.

spk_0 And I think the same would be important for NCDs.

spk_0 And for me, it triggers another thought about prevention versus treatment and why is it so difficult to have governments or others invest in prevention rather than in treatment.

spk_0 And a lot of it also has to do of course with economic interests plus the fact that it's very difficult to measure what has been prevented even though there's some very good efforts done out there.

spk_0 But some of those numbers don't make the same impact as others.

spk_0 So there is an economic incentive and for me as a person who's worked in public health for many years, I still find it strange that money wins over health.

spk_0 When in fact there is no economic growth without health.

spk_0 And I think this is some of the messages that we are trying to strengthen now especially in the World Health Organization especially in these times when there's a focus on anything else.

spk_0 But without a healthy population, what are you going to do?

spk_0 Absolutely. I co-chaired a think tank piece of work on health and the economy.

spk_0 And in the past education was the biggest marker for being in work.

spk_0 And now in Britain it is health whether it's part time or full time work.

spk_0 And increasingly it's mental ill health as manifested through mild to moderate anxiety and depression.

spk_0 Health is the economy.

spk_0 Finally can you share just some of your thoughts about the field of public health and what motivates you to continue working in this challenging field?

spk_0 So I fell into public health. I'm actually a hematologist by training with a lot of pediatrics.

spk_0 I'm not a public health person by training so I've had to learn it on the who-fans-one says on the go.

spk_0 And what I discovered or probably knew anyway was I had to build trust.

spk_0 I'm good at listening. I used to say to people, if you think I've got it wrong, let me know.

spk_0 And hey, I've not come across this before. What do I need to do?

spk_0 I was into CMO for nearly 10 years with perfect timing at the end of September 2019.

spk_0 I stepped down from being the CMO and came here to Trinity College as master, the first woman in that role.

spk_0 But the government kindly asked me to be the UK special envoy on AMR.

spk_0 And clearly that's an unprecedented opportunity to continue leading not just for the UK but for the world.

spk_0 So I've learned it all as I've gone through about communication, behavioral economics and everything.

spk_0 And you know, I love clinical medicine. I loved working with patients.

spk_0 I'm still in contact with some of my sickle cell patients. But public health, you can hope so many more.

spk_0 It's totally rewarding.

spk_0 I think like Sally, I kind of fell into public health. I never was never on my radar. I was never a career path for me.

spk_0 I actually, I studied biology and I was picturing myself saving some endangered species in a jungle somewhere far away.

spk_0 I was trying to save it. It turns out that the species I was trying to save would be human humans.

spk_0 I took a shot and ended up in, well, sort of human public health.

spk_0 And from that mostly moved from food safety further way into antimicobrozzistence, where also my path crossed with Sally, which has been great ever since it is one of these issues that really needs loud voices.

spk_0 And it's just to make sure that, yeah, that that we are heard and it moves from that sort of the technical area where people have known about this for a long time into the political sphere where it luckily is right now.

spk_0 Thank you, Sally and Danilo for sharing your wisdom and insights on the connections between antimicrobial resistance and non-communicable diseases such as cancer.

spk_0 And the ways we can learn from one another and work more closely together for greater impact.

spk_0 This short series is about recognizing the reality of our interconnected world and embracing complexity and uncertainty.

spk_0 We do not have all of the solutions, but we have knowledge, skills, ingenuity and curiosity that keeps us asking questions and seeking greater understanding.

spk_0 This has been a health in Europe podcast and it is produced by the World Health Organization.

spk_0 Music for this episode is by Alexandra Vudez, T or U and Peter Barton.

spk_0 Sound design and engineering for this episode is by David Bart.

spk_0 My name is Mavney Allune and thanks very much for listening.

spk_0 Music

NCDs, AMR, and Policy Crossroads

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