 the pleasure of inviting three panelists to the podium. We have Dr. Alan DeLima Pereira, if you can join us. We have Dr. Sirendra Wong. And Dr. Philip Matthew. Yes. OK. Thank you for joining us, Dr. Matthew. So just a brief introduction. Alan is a doctor from Goa and has worked with MSF in several missions. He's seen firsthand the consequences of antimicrobial resistance in many, many countries. We have Dr. Sirendra Wong, who's an epidemiologist from France. Also an old MSF-er. And now with WHO in the South Asia office here in Delhi. And we have Dr. Philip Matthew, who is the director of React, who is an organization that works on AMR. So Alan, if I may, I'll start with you. Perhaps you can paint a picture. You've seen the two presentations. Perhaps you can paint a picture of what you're seeing on the ground as far as your ability as a doctor to effectively treat patients from infections. Thanks, Unni. Yeah, I think the first two presentations were a really good example of what we see as MSF in the field. And I think me and a lot of people who worked with MSF can say it's quite common in most of the countries we work. We've been using quite broad spectrum antibiotics and for common syndromes and not tailor-made for certain, like we said, based on resistance patterns or local sensory patterns. This has helped us, like we said, improve the quality of care and respond fast in the places we've been working. But now we've been seeing resistance developing. And we have, in addition to the examples that they already gave, surgical projects in Jordan treating osteomyelitis, which are resistant to most antibiotics. So we have experienced, I think, there's been some studies in Afghanistan as well which show huge numbers of antibiotics used. So we definitely see that as a problem. I think one of the things we've really had difficulty in scaling up or have difficulty is in access to bacteriology labs. This is still not standard practice in most of the places we work. And the turnaround time to get a sensory result to tailor-make your antibiotic per patient is still too long in most places where people don't have. And people and health care providers don't have access to this. The next challenge we see or a need we really see is a point of care tests. And it's very difficult clinically sometimes to say, is it bacterial? Is it viral? Should I prescribe or not? And more often than not, as we've seen, we are on the side of caution, not knowing when we may see this patient again to prescribe antibiotics when, in many cases, it may not be required. And I think we've also not been able to, so whatever sensitivity patterns are being done in many places, we've not been able to collate the data across the MSF movement or across different hospitals, not just MSF, in the places we work to provide this evidence back to the treating clinicians to help them decide on treatment. And again, with antibiotic stewardship coming up, there's still not enough clinical microbiologists, trained infectious disease specialists in MSF and outside in most the countries we work who can help with the stewardship or mentorship in this direction. Just a question of clarification. Philip, do we have a database now in MSF where we collect information from all of the different projects like we have for TB, like we have for sleeping sickness? Is that the case? We don't. So we still have much more work to be done. All right. So I'll move on to Sir Indra. So six years ago at the World Health Assembly, this was a big topic of discussion, antimicrobial resistance. What has changed in terms of awareness, in terms of action at the global level in the last six years? Good question. I'll try to be very short, but let's start with the positive side. I mean, I do believe that for the past three years, we have seen a tremendous momentum about raising awareness on antimicrobial resistance. And you've seen that from the two years ago in 2015. And it's considered, it's at the milestone where you had is that from the World Health Assembly at WHO, a resolution that pushed for, first, a resultant about the adoption of the Global Action Plan, which is a milestone. And secondly, recommending actually strong recommendations for country to develop their own National Action Plan. It's kind of easy to say, but very difficult to do. And the condition about the Action Action Plan was to make it align with the Global Action Plan, where it's not only a paper where you could have empty actions without interconnection between the different sectors. But this is my, so I can expand on the detail. And recently, in last year, in September, this is the first, actually not the fourth time, that we have the health issue that was brought up at the UN General Assembly. And it was about recognizing the problem of antimicrobial resistance as something that is a global threat for health security. And this for security itself of mankind, but health security as well. And that was a tremendous advance. If you want to compare it, this was the fourth time that the issue was brought at that level. The first time was HIV, Ebola, and non-comicable diseases. So MMR is at this stage now, where it's leaders of the world know of the threat caused by antimicrobial resistance, more importantly, antimicrobial resistance. So you talked about the global, first of all, there's a global will now, but also a clear will to align national programming with international priorities as well. Perhaps, Philip, you can tell us what's been happening in India. I know that the government has formulated a national action plan. Perhaps you can talk a little bit about what that action plan entails, and perhaps the breadth of that plan, the reach outside just the Ministry of Health and all of the other actors involved. Thanks. Thank you so much. I am Dr. Philip Matthew. I'm not the director of React. I'm representing the head of React Asia Pacific. But you're the director for us today. Thank you. We give you the title. So India has formulated a national action plan on antimicrobial resistance in line with the global action plan very recently. The best part about it is there is no finger pointing. Usually in all discussions about antimicrobial resistance, it's all about you cost it and you are responsible for it and all that. But I believe the national action plan in India is a more progressive document. There is no finger pointing. What, why, there are some references about who is responsible and all that. But it's mostly a moving forward document, a document about how to move forward and what are the things to be done in short term, medium term, and long term. Another important thing, another important fact about work till late before the national action plan was formulated. All the departments or government institutions are working in all the organizations, even the civil society organizations, departments, institutions, were all working in silos, totally disconnected to each other, totally compartmentalized. But probably with the coming of national action plan, there'll be more integration in activities as in multiple ministries can come together and formulate kind of implementation plans together. Other things, apart from the national action plan, I believe there has been a lot of over emphasis on the medical healthcare sector till late. But the national action plan has realized that probably we should be looking at the non-medical aspect of antibiotic use also. Because as server say, almost 70% of the total antibiotic production is consumed in sectors like fisheries and animal husbandry, basically as growth promoters, not as curative components as growth promoters. So it's high time we should be looking at that. So there is a lot of emphasis given for the farm sector, where antibiotics are being used as growth promoters. And of course, the need for integration between government departments, civil society organizations can do up to a certain limit. We realize that if you want to take forward the message, we have to engage all the government departments, all the government ministries, all the government departments concerned, all the government institutions and the key administrators have to be on board if you want to take this message forward. I'll give you a small example, how antibiotic response that we have been discussing antibiotic response for a very long time in the academic circles, but it hasn't reached the actual people who are working on the ground. Recently, we had a workshop, we found out that the Kerala University of Fisheries and Ocean Studies, it's a state university for fisheries only, a specialized university for fisheries, has published around 15 articles in reputed international journals on antimicrobial resistance, but the administrative people who came for our workshop, mostly people above the rank of Aston directors, deputy or joint directors from the department of fisheries, had very rudimentary knowledge about, had a very rudimentary knowledge about antimicrobial resistance, in spite of the fact that the state fisheries university was able to publish 15 articles in reputed international journals, that shows the disconnect between academia and the actual policy makers slash administrators. So possibly the national action plan can give us a comprehensive platform by which we can take forward our initiatives in the field of antimicrobial resistance. So we've talked about practice, we've talked a little bit about global will, we've talked a little bit about policy. So what we'll do is we'll take a few questions, but when I come back, I would like each of you to maybe provide three priorities going forward in research, in practice, in research and in policy, all right? So questions, okay, that's one of the things questions, okay, that's one of the first, please state your name and where you're from. Hello, yeah, great. Good morning everybody. I have been working as a junior resident, my name is Dr. Dhyan and I have been working as a junior resident at Paras Hospital Gurgaon. The topic here is antimicrobial resistance. I'm sorry, I came late. Important issue was raised about the use of antibiotic in the viral fever. But I come from North India, an important issue was left, that use of antibiotic without any prescription. If you go anywhere, I come from the small village of Varanasi. When I go to my village, there is a minnows of antibiotic use. Everybody using amoxicillin, everybody using SIPLOX. So do we have awareness program number one and number two, we need a strong legal action against those who are giving antibiotics, especially important ones, without any prescription. MSF is doing any work for legal action in India. Thank you and we have, we raised that point in the last presentation, but we'll come to the legal part of it. There's another speaker there and then Lena. Thank you very much. I am Dr. Vikas Agrawal. I am a regional director for Kala Azar program and also regional coordinator for Fleming fund, which is looking after AMR related issues in South Asia. So my kind of comment to all the three panelists, one is that, you know, in fact, I was having a question which you asked that whether MSF is maintaining the data set. And I think it would be very critical to have data from the MSF site and not only from the MSF site, but all the sites which National Action Plan is working on. But the real challenge would be to have sufficient microbiologist and data surveillance point in these centers and have the capacities. So with regard to the kind of focus, the question which you had, there is a emphasis Fleming fund, which would be supporting 30 countries on AMR through Department of Health UK. So the emphasis would be to strengthen the surveillance point and AMR resistance data collection and analysis and reporting into WHO nets. So that's a kind of comment. Thank you. So far there have been no questions for the panelists. I would like you to reformulate your comments as questions. But Lena, perhaps you have a question on the legality, legal aspects that the first speaker asked. A question on the process, on the AMR policy and maybe, you know, I shouldn't be asking you, why should we asking the government? Did they hold any regional or statewide consultations on before formulating the policy? Because the WHO has sort of given up blueprint of it. But it does need to be tweaked. And there are going to be very specific issues that are very contextual to particular areas, particular countries. Did the government do any of that? So that would be a very useful input into the future of working with the government. And on the legality, we can deal with it. We'll come back to it. So Dr. Mathew, maybe one more comment on. For the national action plan, for India, there was no regional consultations as such. As in, a decentralized consultation process was not followed as far as I know. But there has been a reasonable amount of consultation which happened based in Delhi. With multiple organizations, Center for Science and Environment was involved. Multiple organizations, civil society organizations, React was also a part of it. So there was a fair amount of consultation which happened in Delhi. But regional consultations probably, you know, we need to work out more on that. Thank you. I want to thank you for this question. I think it's a key question for me. There's a lot of confusions on the fact that when you look at best practices in terms of policy, when you look at overarching policies, for example, preventing the sale of antibiotics without prescription, for example, or the growth for murders. And I'm not pointing out, at India, but it's a regional picture of the region that you may have policies, overarching policies, but getting to the level of forcing those policies is the major issue with a lot of problem with governance and things like this. But the real issue is about making sure that the government is taking charge of developing country-specific policies to make sure that this overarching policy would work. And I just wanted to highlight this challenge that needs to be really taken care by governments. And this is one of the things that we thought about aligning the National Action Plan with the Global Action Plan. It's really about making sure that you have all aspects of the Global Action Plan in the National Action Plan. And with this approach that it covers all sectors, including policies, the regulations, for example, not only having the Ministry of Health handling the National Action Plan, but having all other sectors like the agriculture part as well, but being inclusive of the civil society and of course NGOs and the private sectors and the manufacturing industry. So this is the comprehensive thing that we would like to promote. And within that comprehensive approach, this is one of the conditions of the alignment is to make sure that you have a monitoring and evaluation system embedded in the National Action Plan. And we see it as key to make sure that this National Action Plan is not about a document that you put on the shelves and you forget about this. It's making sure that countries now are accountable because what I say in the National Action Plan is also about showing the gaps, but making sure also that we can measure progress. But Sirendra, maybe I'll take the prerogative to ask a question. How does the National Action Plan, for example, very specifically address the issue of the way research and development is done, where, you know, how intellectual property and how the way innovation is structured today, how is the government trying to address that in India's known as the pharmacy of the developing world? How are we changing the discussion around drug production and research and development? This is a question for Sirendra specifically. Okay, I wouldn't go too much in detail, but let me get into the bigger picture of the research aspect of development. You wanna take the question? No, no, no. Okay. I do believe that, oh, I do believe that, okay, I'll have to be very short. I do believe that the approach for development and research in India was the fact that you have very extremely good institutions that are doing research. But if you look at the bigger picture, they're all scattered working in our own ways. And if you compare with countries that have the potential also to do in innovative approach in terms of new antibiotics or new diagnostics, for example, or other intervention is the potential for the government to maybe coming up with an approach where you will have a capacity for those institutions to work together with the same, and I'm not saying a naive way, but more a consortium approach with these common objectives. So I try to be short in that and stop here. So we'll take one more question and then we have to go round up the person here. Thank you. I'm Dr. P.K. Bansal from Merit. It's my personal experience comment. Even in the remote area, CSC, PSC, small villages, we should not start the day one antibiotic empirically until as the patient is critically ill or deteriorating very fast. And if it is so, the patient should be transported to the nearest multi-specialty hospital having a facility for the culture and sensitivity and depending on the protocol of that particular hospital, the available data regarding the microbes available, most susceptible antibiotics should be given. That is the I think best way. And probably most, we should avoid a polypharmacy or polyantibiotic therapy. Yes. So I mean, it's clear that the issue cannot be addressed with, you know, that we need a multi-sectoral approach. We need to approach it from the ground up all the way to the level of policy. So what I'll do is I want to come back to each of you and perhaps you can give two or three priorities in the, for example, Alan in, as a physician, what are the two or three things that need to happen to change the game? Yeah. I think I just want to start by saying why we want to rationalize antibiotic usage. The thing as MSF and as all of us we want to keep in mind is we don't want to give up access to people who need it to save their lives. So it's a bit of a give and take while ensuring people don't lose their lives because of lack of antibiotics, we need to make sure people have access to antibiotics and we rationalize use. As clinicians or as people who work with patients, I think a couple of priorities, one is definitely a scaling up of stewardship programs with bacteriological lab sensitivity. Like he was saying, I don't see the point of referring to hospitals, but maybe make lab sensitivity data more available even at a peripheral level in the future. In the ideal world, infection prevention and control is something we've not spoken much about and hospital-acquired infections because that's where a lot of the resistant ones spread and something where we can improve. And the third thing, I think we need as clinicians is more operational research on point-of-care tests and things, aids that can help us at the bedside of a patient to make the decision safely and effectively. All right. So hygiene, diagnostics, and the first one. Stewardship bacteria. Thanks, Alan. Sir Indra, in terms of three sort of priorities, in terms of the research. Oh, research. Okay, I'll put it that way as well. I mean, of course the research is to have better diagnostics, better new antibiotics, but this is easy to say, but the challenge is huge and I don't want to expand. But I wanted to raise the issue of having data and so far, AMR is a complex issue with the combinations of different conditions, different antibiotics, I mean, you know, even antibiotics, but also anti-fungal agents or anti-parasitic agents plus the numbers of antibiotics, which makes it very difficult for us to produce data. And of course, these days I really needed for awareness and to have a better understanding from not only the population, but also the higher level on what's at stake for it. And so far, we don't have any information on the trends. We have data from grassroots, we have some national data that shows the trend, most importantly from developed countries, but nothing from our region. And this is one of the major objectives that we need to achieve. Have there not been some attempts at global registries to plot resistance patterns, et cetera? What success have they met with? It's work in progress. I mean, there are, if you, I want you to refer to this global survey that was done in 2015 and also the Global Surveillance Report in 2014, I think. It really shows the gaps. It's just that we have a number of threat that goes from ESBL to Gabapinem resistance or MRSA, Mancomycin resistance. But if you look at the pictures in countries, most of those information is missing. And this needs to be taken care of. And what I'm saying missing, it's not only missing in the human health sector, but it's also in the animal sector. And looking at surveillance for consumption, but not only consumption in the human sector, but also in the animal sector. And the potential for those antibiotics of resistance spread that spread through environmental contaminations, these we need data. We don't know the magnitude of the problem yet. So I mean, given what you said, it's happening to see that India does have a national action plan. It has 12 ministries coming together to address this. What, according to you, are some of the things that the action plan should sort of recognize and emphasize and prioritize for the coming years? Our national action plan, incidentally, is a much larger document as compared to the global action plan. So at least the document size-wise, we are better than the global action plan. But seriously speaking, an intersectoral coordination, which has to, on the ground, there has to be an intersectoral coordination. And all the stakeholders has to be brought on board, actually. We have been focusing on ministry of health for a very long time. Multiple countries have been focusing only on their ministries of health. But other departments, especially at least the people dealing with animal husbandry, fisheries and agriculture, and also environment, needs to come together for a reasonable outcome. Otherwise, it may not be possible to obtain a reasonable outcome. Second is collaboration between civil society organizations. A lot of organizations have been working very discreetly, probably if we can come together, synergize our efforts. We can make better output can be possible. And of course, genuine concerns of people engaged, like my co-panelists were saying about point-of-care diagnostics. In our informal discussions with health administrators, at least the southern part of India, we found out that access to point-of-care diagnostics, like pediatric centers being equipped with simple things like blood counts or access to a CRP, improved antibiotic prescriptions, actually rationalized antibiotic prescriptions by a huge extent. Also, we need substitutes. People are using antibiotics at group promoters in the farm sector. We need some substitutes because their yield is at stake. They won't be backing off without, if they don't have a proper substitute. So these are things that we should be taking care of, of course, and research should be focusing on. There should be some research which should probably focus on things like faster turnaround time for intensives because empirical therapy is a wrecking havoc at least in the hospital sector. So things like that has to be, I believe we are running out of time, so stop. So I'm being hounded off the stage, but I wanna thank the panelists. I know we haven't had enough time to discuss all of the aspects of public response to AMR. But thank you so much for joining us. And I'll hand it over to Philip. Yep.