 We have sessions on epidemics. Ebola and so on was very high on the agenda but now we have also let's say man-made epidemic and an epidemic threat and that's the an epidemic of untreatable infections and you know with the question will we go back in the doom scenario to the area from before the West Penicillin and we'll hear from our experts here what the causes are and particularly what we can do about it and the good news is that there's real momentum building up in terms of awareness in terms of action at all fronts because this problem is extremely complex and requires multiple actors and multiple solutions in order to get it under control so we had also an industry declaration that just came out yesterday so that's from the side of the pharmaceutical industry we have the G7 it was on the the summit in Germany was one of the of the topics and now we're here so our panel is also represents the diversity of the issue we have Andrew Witte CEO of JSK Minister Skippers from the Netherlands Minister of Health another Minister of Health from Minister Greur as you know the Minister of Health of the G7 Jeremy Farra from the Welcome Trust Director and Joanne Liu from as president of MSF, let me start with asking Jeremy how do you see things what's the problem thanks very much Peter and it's pleasure to be here there is obviously a huge problem we it's been talked about many times but I'd like to start on a bit of an optimistic note if you we are not passive observers of history if you identify an issue and then you work towards solutions you can change the course of things and I think we're at that tipping point now where if we make the right choices we can actually change the dynamic of what's happening I think I'd like to frame it we need to think of it infectious diseases but we need to be aware that all of the progress that's being made in some of the non-communicable diseases the major breakthroughs in cancer therapy diabetes care surgery all of these are actually dependent on on antibiotics and so therefore we cannot just frame this in the context of infectious diseases and we cannot just frame this in the context of the lower middle-income countries this truly affects every billion I believe we're at that tipping point where if we act we can have an optimistic scenario if we fail to act we could be into doomsday we portray this as a market failure and I think sometimes a market failure is a bad use of terms I think this is a failure of public health and I think we're going to need a new contract between the public sector the private sector academia philanthropy in order to address this this is just not a failure of industry industry is undoubtedly part of the solution but it is going to have to change its models of working in order to address issues around access in particular like to frame it in five areas firstly we have to learn how to conserve what we've got in a better way that means prevention it means changes of behavior it means engagement with society and it means of course things like vaccination we have to involve both the human and animal sector because the vast majority of antibiotics are actually used in the animal sector and the resistance comes through into the human sector and vice versa and we've got to frame it in terms of innovation in research and development whether in new drugs in conserving existing drugs or in the development of preventative measures and we've got to understand the value of this class of of interventions we've on the whole talked about them in they have to be cheap and they have to be affordable and that's very very important but we also have to truly value their contribution to modern medicine and that's going to require changes in the way we see volume and access and we're going to have to require policy changes and that gets back to my comment about public health so I believe we need this new contract between industry between the public sector and with society in order to value what we've got to conserve what we've got and develop new approaches thanks for that. Thanks Jeremy that's very clear Mr Schippers the good news is also that antimicrobial resistance has made it to the the political level because without that we won't be able to to move and particularly the reports also by Jim O'Neill in the UK have been really instrumental in waking up you know the world to say so so how do you see things from your position as Minister of Health? I think we had also a momentum 10 years ago but we failed to be determined enough to make a big steps and solutions it's a global problem that is an advantage but also one of the difficult things to solve secondly I think it's a silent killer Ebola we talk a lot everybody is talking about it seeking for solutions but antibiotic resistance we talk a lot about it but the public industry the citizens don't know so I think it's very crucial for us also to make them aware about prevention prudent use but also about that we have a problem with each other because if they don't know we have a problem they're not open for solutions either and the solutions are not only in the medical world they're also very necessary to make measures to take action in the veterinarian world and that's also very a topic that is that is very sensitive sensitive in many countries because it means that also farmers have to change the way they have their business models the way they treat their livestock and no preventive use of antibiotics or and for a whole cattle and not using antibiotics as a grow facilitator to to to see how growing gets faster so the one health approach is also necessary but also difficult and last I want to make a real we need to make come from paper to paper to implementation because we have a lot of sessions and we talk how important it is to make a solution so as a president of the European Union we organize in February a conference for the first time in its existence between ministers of health and ministers of agriculture to see how we can really make solutions and come from paper to action not to have a national action plan but to implement your national action plan to have peer reviews not to control each other but to help each other to see obstacles and see how we can overcome them and of course also very important new business models new working together in PPP with the industry to see how we can get new alternatives and new antibiotics not to use them but to have them when we need them all very good points for any action now Joanne and you're not only president of MSF but you're also still practicing emergency physician you go there where the patients are how do you see things well for us you know as I would say our first line worker is the big driver for antibiotic use is fever and then I think it's the same everywhere and our main issue about fever is the fact that we don't know what are the causes of fever so somehow we overuse antibiotic so we see it you know right away now in in Pakistan 80 percent of our newborns have in their bloodstream with a concrete fever resistance bacteria same thing you know we have appalling figures in AMAM where our well-winded patient come with a 55 percent miscarriage resistance when they have a steomylitis so we are seeing the same musical situation that we will save a patient from his in Syria from his amputation but he's going to die from pneumonia but in Montreal my old relative will be saved from his triple bypass was going to die from pneumonia so it's the same category of problem and we probably can find similar solution that would benefits everybody the the reality is in developing countries and less developed countries we don't know the scale of the issue we have no micro data especially the primary healthcare so what we see you know in our context of work it's everything is magnified easy earthquake slums rural remote area it's it's it's crisis time and so patient or either not immunized they malnourished remember the medallion children so when we see those patients we have only one shot because they will not going to come they won't come back they won't cross another front line to come and see me so by default often we overuse antibiotic so solution i was thinking about that is there's good there are solutions upstream and downstream and there are like technical solution and political solutions on the technical side upstream is we we have vaccine we know that the chemical vaccine you know if we are using it will prevent lower sleep track infection he just need to be available for all the countries we need to do more in friction control we need to in our healthcare facilities we need mini lab to be able to identify the box but we all know that all we've talked about it's so difficult to change behavior so difficult and then we've seen it you know with hiv we've seen it with malaria but what we have achieved from 2000 to 2015 is we decreased by 60 percent the mortality rate uh in malaria because we have the right new diagnostic tests rapid diagnostic tests and the treatment so we need new rapid diagnostic tests for fever that will differentiate you know a viral illness from a bacterial illness or at least will tell us the which one or the severe bacterial infection and this will allow to treat the patient who need antibiotic and the one that doesn't need it won't get it this would be the real game changer and then downstream we need new drugs of course so all those tools if we find them they're going to benefit everybody last point it's about political solution it's the global security agenda is driven by national self interest we've seen it in Ebola we're still seeing it in the migrant refugee crisis and we're still there about the Middle East but drug resistance infection is not about security is not about national interest it's about health it's about saving lives it's about government taking action because health is a public good and then we need we do need to provide but the reality we're working in failed state and so we need the right trigger to work in those states and our issue is we don't think that fear can be the driving force we've seen in Ebola we're just going to hack when nations feel threatened so we need political will beyond self-interest to find the right trigger so my summary hashtag rapid diagnostic tests for fever hashtag health is probably good thank you thank you that's the mother way of addressing it and also thanks for putting it in context but also diagnostics I mean the key there is the longitude price which is you know has launched the price for actually exactly that to discover a rapid inexpensive diagnostic point of care and that would rationalize the use of antibiotics and thereby also limit the spread of infectious and resistant factions andro we had the declaration of the industry so companies are taking up the challenge although after years there was not much investment in antibiotic development so how well just maybe just this highlight a couple of points so the declaration was published yesterday I think it's pretty unprecedented actually and there's about 85 private industry companies now biotech large companies many companies some involve some not directly involved in the space all signing up to very much the kind of themes you've just heard actually from all three of the previous commentators in terms of conservance in terms of focusing on things like diagnostics in terms on in terms of thinking about how to develop the marketplace to be responsible but at the same time incentivize so that's all in there I'd like to do I'm sure we'll come back to some of those I'd just like to drive the focus a little bit at least in these comments on something which I think is a little bit taken for granted which is that actually discovering new effective antibiotics is really difficult really really difficult we've been in antibiotic research since the early 1940s and we've never stopped in fact in the last decade at GSK we spent a billion US dollars on antibiotic research in the company and I'm very pleased to say that we have a new first in class product about to go to file looks excellent highly effective in plague tells you something immediately the fact that we're developing an antibiotic in plague and was the last time anybody talked about plague great collaboration with bar the US and other organizations to make that happen but the point of that antibiotic is its future is likely to go towards things like complicated gonorrhea and the kind of very difficult infections which were starting to see around the world so we're there now we did some work we look back over our history over the last nine or ten years and we were able to get we worked with one or two other big farmers and we looked at three companies between the three companies on average over the period of nine or ten years we've done something like 60 or 70 high throughput screens in the antibiotic space to look for particularly gram negative antibiotics so about 200 hts intervention so hts essentially is screening your molecular libraries so in our case that's probably two million chemical structures now you can then say okay the other two companies let's imagine they have broadly similar kind of volumes you're talking gigantic amounts of data to be trying to be exposed to look for starting points for products out of the 200 high throughput screens in three different companies over a period of nine years there were precisely zero hits now it's not because we're all completely stupid it's because it's a really really difficult space to make progress so that the bit i'd like to just draw attention to is first of all just by writing checks out isn't going to solve anything i honestly don't believe that i think what this is really about at the first point and this obviously is what will give us some cause for optimism in 10 15 20 years not tomorrow morning we have got to drive some really strong basic science coming from academia in research in biotech everywhere in the normal way if i can put it that way we have got to drive a greater level of open innovation we've managed to construct some very interesting semi open relationships with synovia i think Olivier is in the room with where we've seen some great progress there with the two teams working together we've seen a much broader open academic collaboration with multiple companies involved what do we need to focus on gram negative how to get drug load into patients without creating toxicity because even when we do find a hit the drug load is driving too much host toxicity and it kills the programs how many times have you turned on the radio in the morning and heard a university professor claim they've discovered the first new class of antibiotics in 20 years how many of those classes have been launched and they all go down on drug talks because we're killing the hose quick and they're killing the bug so that that for me is a big space so something around academic industrial collaboration how to energize which bridges into the market incentivization how do we turn on the biotech sector how do we turn on that incredibly inventive layer of companies who bridge ideas out of universities how do we get them excited in this space at a scale which really moves things forward and then how do we get lessons learned so that we've got pre-competitive understanding on things like tox management all of the things which are killing these drugs as they come through the system just as we've done through things like IMI and other programs in things like liver tox on traditional small molecule non antibiotics so that's a big focus for us vaccination is a huge opportunity we we we think I think Lancet published recently that effective PCV vaccination reduces subsequent antibiotic use by about half something like that huge impact we're very committed to try and do our part to make that happen the the role of Gavi in the advanced market commitment which without which there would be no PCV vaccination of scale going on in the developing world is an extraordinary example where the right intervention can absolutely drive the right behavior is not perfect but it can really move things in the right direction I don't know if that's what we need to do in antibiotics probably not but we should be inspired by the idea that we did something in a field it worked we should we should scratch our heads to come up with what the version of that is in this space yeah so also innovation is really going to be important but also I think we we may have to look at what's still on the shelf and what we don't use a combination therapy and then and then your point about vaccines I mean someone who doesn't get a child doesn't develop pneumonia the three seeds the pneumonia a vaccine against pneumococcal pneumonia doesn't need antibiotics so it's it's like contraception saves mothers reduces maternal mortality just just your point about on the shelf I think I'm Ryan saying that the PD1 inhibitors which are creating the most extraordinary excitement in immunology have been on the shelf a while yeah took as molecules right took as a took a while to figure out their role but it you know that is what we need and we've seen it in TB actually I think in TB where almost nothing happened really really really for 20 or 30 years as there's been a mobilization of frankly you know the Bill and Melinda Gates Foundation welcome the Tres Cantos operation that we run all of the various at that opening up of thinking and that plurality of innovation we're now starting to see some real prospects of something in tuberculosis and malaria also yeah so I think I think there are good reasons to be inspired the question now is as Edith said how do we connect the words and the aspiration on antibiotics to some of the models which we know work and how do we just shape those a bit and then industrialize in it and making something happen go to scale so minister good Germany has been really in a strong leadership position on this can you tell a bit about what you're doing the plans and the action that your colleague from the Netherlands thank you so much first of all I would agree with you Peter that we have a momentum in Germany people were surprised that the G7 summit of the heads of state and government addressed an issue like AMR and suddenly it was not only an expert issue but it was in public debate for a while and I hope that by the work that is done now by the Dutch presidency in the European Union as a it's not just a firework but it's continuing to be an issue that is to be addressed strictly Edith mentioned correctly the work of a silent killer it's not like an earthquake everybody can see it similar maybe to climate change that you are slipping in a catastrophe without seeing in that direct way like a Vulcan or a earthquake that's dramatic things are happening I would divide the things we are debating now and those were it's a question of political will of preparedness to change behavior and mentioned I would describe the whole area of prudent use one health approach good stewardship mostly being a question of political will we know about hygiene about diminishing misuse one health approach these things are thought through in a way but they need to be implemented and that is that area where we have a lot of things to do of course also a new invention where we talk about fast speed diagnosis to help prudent use there is also need of new intellectual work but I would say mainly to say it's needed to have one health approach it's a question of political will when it comes to the point Andrew Whitty mentioned a lot of intellectual work is still in front of us I think the market failure Jeremy Farrow mentioned that we asked and Whitty and his team invest a lot if you have something to fight superbacks please sell it carefully that's not an easy business model of course so the way how to delink the profitability and the quantity of sales is an intellectual challenge for a market economy for using market powers for innovative activities and so we have to debate these models there are some on the table we used our g7 presidency to ask uscd and the boston consulting group to make studies about incentives they are all available on our website because we want to make it a public debate not just an expert issue how we can use prices like the price that is the award that is made by the UK government the question of a market entry award could that be one or not we see the contribution of the declaration published by the pharmaceutical industry yesterday as this morning to be frank we have to debate about details some of it is a commitment thank you some of it as a request we have to debate that and we did when we debate about fair risk sharing for example you're talking a lot about predictable market conditions if we take the risk by the public sector in a new way of public private partnership what is the benefit for the public side for example the affordability for those in need even if they cannot be the high price payers so I think we need to balance out in a fair way we have not too much time how to reach that delinkage between investment in research profitability on the one side but also clearly to have a predictability that makes it possible thank you very much Herman to really to highlight these very practical golden quote details but that's what will make or break the whole you know the the new innovation that we that we need and and Jim O'Neill's report has some very practical proposals but again have to be worked out and there has to be not only consensus but agreement about that one point I'd like to make is that we should also not forget that there are still millions of people who do not have access to antibiotics to life-saving ones and and as a result there are people who die from kind of pretty banal very treatable infection so we have to really work on both sides I mean access where it's where it's none and then making sure this rational use that we don't create that pressure maybe Peter I can just add a short point we talked during the G7 summit and during the G7 health ministers meeting about supporting WHO in implementing IHR and here there is a link if we talk for example about obligatory prescription we need of course a basic structure also poorer countries to implement such an obligatory prescription and that means we have not only to take health care but really health system put in place in states in Africa and elsewhere and the G7 summit declared that they want to reach the aim to stop 60 countries yes in implementing IHR and we will in the end of the presidency we will publish and I'm confident but it's still work to be done that we reach that aim because it's needed to have prudent stewardship not only in rich countries to enable countries to have these fundamental things started with obligatory prescription with hygiene and all these basic fundamental things absolutely and I said it said it is a global issue and and I'd like to support what Joanne said and that is that you know this is not only about global security and these initiatives if one can link epidemic preparedness and tomorrow there will be a big session on that with surveillance and action on antimicrobial resistance I think that's a very rational use of resources if these things are going to be handled in in parallel there's going to be a waste of resources so okay the floor is open for discussion we there's a lot to the discussion please identify yourself and and limit your intervention also to very well one minute okay yes please sir you have the behind yeah first and then Francis my name is Stefan Tanda I'm a board member of royal DSM we've been producing antibiotics for 70 years proudly and in a very clean biotechnology manner very much welcome the O'Neill report thank you for supporting that and the one additional component I wanted to make is I missed in all your discussion one of the points that the O'Neill report highlighted which is there's a third major source of antimicrobial resistance next to human overuse and animal use it is heavy pollution in the manufacturing of antibiotics particularly in the developing world if you YouTube polluting to heal polluting to heal it's a documentary made by an investment management company Nordea I don't need to describe anything else and I think you need that third pillar in your efforts and I would ask the minister skippers in the in the February event to add that third pillar to address this issue we are fully behind you we offer tests we discourage all using animals we offer alternatives to antibiotics we need to get at that but we need to get it with all three pillars and to be honest the polluting is a major pillar we source many products from those countries not for medical use but the other use is an often the trace amounts of antibiotics because it's everywhere in the water from those pollution thank you thank you very good point at uh Francis Collins hi Francis Collins director of the national institutes of health in the U.S. certainly welcome the momentum that we see represented by this group here gathered this morning about a problem which as has been said has been with us for a while but we haven't really pulled all the resources together in the way that we need to from NIH's perspective we're fortunate that in the recent budget we were granted an extra 100 million dollars to work specifically on antimicrobial resistance and look forward to working in partnership with all of you in that regard I really welcome the comments from Andrew witty about the opportunity for additional open innovation partnerships about discovery there are some interesting things happening there such as the use of chips to discover soil microbes that are making natural products which we didn't know about before like tycho back then we have methods for doing toxicity testing that are perhaps more rapid than what we've had in the past and certainly recognize the need for that if we're going to be able to identify compounds that are actually useful for human use we also as the UK have put out a prize for rapid ability to detect resistance particularly from gram negative rods so that in the clinical setting one knows when you're dealing with a highly resistant organism one pitch though i'd like to make is for databases the more that we can collect genomic information which is not that complicated or expensive anymore on resistant organisms to develop a national international database of what's out there the more rapidly we'll be able to understand the epidemiology of how these particular organisms are spreading and how their resistance is encoded and presently that still hasn't quite come together that way that it might finally i might say clinical trials remain a challenge because you would like to have ready to go examples of people who are infected with highly resistant organisms whether it's pneumonia or urinary tract infection or septicemia so that when a drug is ready for testing you don't have to try to line up those individuals which is very complicated and difficult to do and i don't think that's a solved problem but we're certainly interested in international collaboration around that space as well yeah thanks Francis all very practical options and congratulations on the budget for NIH in general Seth Berkeley please thank you Peter and i just want to build on some of the comments that Andrew and others made it's interesting you talked about the pneumococcal vaccine pneumococcal resistance began in South Africa it was interesting as they rolled out the seven valent pneumococcal vaccine we saw a drop obviously a pneumococcal disease but we also saw the pressure from antibiotics going away and we saw resistance disappearing as they moved to a higher valent vaccine we saw the drop again but the other points you didn't make which i think is really important is that if you get rid of the disease in the children the elderly then don't get infected and of course that's the problem this was the old man's friend always and so you know we've rolled out the vaccine in 54 countries now we're trying to do the same thing with rotavirus vaccine which is also obviously in diarrhea over use of antibiotics so i think as we think about not only antibiotics we have to think about creating new vaccines which there'll be some sessions here as well but then what are the mechanisms to make sure that these are made rapidly available and the amc was interesting because within one year of the new pneumococcal vaccines coming out they were rolled out in the developing world unprecedented all good point and illustrating we need more than just new antibiotics yes please do we have two requests here from Jeremy Garrocox from the UK could i maybe follow on from that just maybe ask the panel for some comment on the ability and the challenges of delivering new vaccines that's been mentioned on a number of comments earlier in today's discussion and secondly within that within the the ability to speed vaccines to the market is the framework the regulatory framework right to enable or to enable the challenges to achieve an approved vaccine and by that i mean the burden of proof of negative proof i.e. proving what a vaccine doesn't do to be able to enable it to get to market we'll come back to when we have a panel discussion afterwards you know so let's see we can yes please my name is carolina sacks i'm from axe foundation a swedish-based foundation and we are running a big project that is industry driven from the retail food retail sector on the use of antibiotics to land-based animals and what my worry is who's really taking the lead in this subject because we have the WHO and we have the FAO and we have lots of different but who's really taking the lead so we won't have like a climate discussion that goes on for years until we get to an actual deal that needs to be taken probably in the UN assembly but that is really my who's taking the lead and why i think we really need the lead to get fast action i agree i think that's why it has to be at the political level that goes beyond the sector and but we'll go around first and then we have post office i see and then mario polkini well we developed a new antibiotic a new drug for xdr mdr tb bidak polin sorry from well post office from johnson and johnson the answer and we developed a new drug for an atp synthase and very unexpected target for for tb only for tb mdr tb and lepra i must say mid fantastic collaboration from the regulators in the world we did a very accelerated program one phase two b study with the fda the fda approved it today it's available in many countries xdr tb mainly russia south africa in southern africa but the challenge is of course then you have to limit to really xdr tb so first we went to the cdc within six months guidance only for that area then with the who within six months guidance only for that area we priced it very responsible so that it was accessible but you end up with a non-commercial non viable product and that you can it shows that you can get to new antibiotics fast if needed but we have to find a way to do that much broader than a one time off yeah and basic research the regulatory part is there the clinical part is there but the right incentives we got the voucher an accelerated review voucher from the fda which is an incentive but it's not big enough to massively mobilize the industry and i think the industry and i agree with andrew we can do a lot in order to bring new antibiotics if we work together with the basic research institutions the academia and and the regulators um but the experience is good when you have one you get it there thank you paul and marie paul kini from the world health organization just thank you indeed as was discussed this is an this is an area which is beyond health alone and uh and there has been a request uh to the secretary general to organize a high-level meeting on amr in september in the unga so i hope that this will again incentivize all sectors to work together so at who on the global action plan on antimicrobial resistance we work already with oie and and f a o but but you know we need we need more of that so uh there needs also to be a few experiment to work on to work out new systems to and new models so we have just launched dnd i n w h of a drug for neglected diseases initiative n w show an initiative to look at existing drugs to look at combination of those to look at drugs for children and we hope that this is where this will be another approach in addition to developing new antibiotics to find new avenues to treat people and this will also give an opportunity to test new model for for stewardship uh how can these be preserved in the future thank you very much thank you my people and i i think um let's address some of the questions and that that came up and um some i think is a very important one on uh where will all this be uh taken on that um you know since it is not only one health but it will involve and uh lots of individuals was quite interested by what you said it about the the EU initiative where you bring at least the minister of health and minister of agriculture together and also have accountability can you say a bit more about that and then indeed what the marie poll says so how how do you see that because it is an important question where will it all come together um politically did did you need to have a dialogue between the ministers of agriculture and health and also environment but i think we invested as dutch government quite a lot of money in uh investigations in the environmental impact but i think that um it's important to have this dialogue not only in health but between different sectors and also to put it on the agenda of the general assembly of the united nations because you can't solve this as a country alone so you need leadership political leadership uh internationally and so you had the g7 we are all members of who uh who works together with fio and oid so this is the way to go on a political level to see how you can make not only strategics and not only agreements but the second step i say it again is implementation because we make all kinds of declarations and we sign this but we really have to implement them and we have also to see that other countries overcome obstacles that they meet and we know these obstacles from each other so we can share how to overcome them so i really think that an open transparent dialogue on a political level is very important for amr and i'm very happy that it's not only a problem of ministers of health because then we won't solve this problem we really need to involve the cabinets we really need to involve the international political um decision makers absolutely and i think your point about that um learning from each other is important we particularly use in um promotion of uh growing of animals and uh prevention of infections it's a huge economic issue but there are countries that have managed to do it to control it without let's say economic damage to the farmers i mean the danmark and sweet and you have in several years exactly but it was not a dutch invention we looked at danmark exactly and saw how danmark did it and then of course it was not copy paste but we uh translated it to the dutch situation and so we can learn from each other and then really you can make big steps it's because 60 percent lower use of antibiotics in uh and we're still the second largest exporter of agricultural products so it doesn't mean that you have a bad um your business case worsens exactly that's why i think also a peer review can be very useful not to you know to punish anybody but to learn yes have one you have a global action plane uh made in jeniva last year during the world health assembly is a good framework right and it was connected with oie and others that brought in their expertise so i think there is a framework but during it was during these world health assembly that we launched with some colleagues's initiative to the u.n general secretary to make that high-level meeting also at the general assembly because we believe that it should be on that level also to be visible for all sectors that's the first thing uh concerning what edith mentioned learn from each other one of the small steps we did during the g7 work was to make a best practice uh brochure for all of us in g7 and uh brought it also to other friends and just to show what we can learn we can learn if we debate with our farmers we immediately hear hey what's with those in the Netherlands and danmark and all these others if we do it together and we learn from each other it's much easier the last point since it was mentioned the collaboration with regulatory work we have on the german side we have a dialogue between pharmaceutical industry academia and the government that will finish its work with a report in april and we have a working group there especially on the regulatory framework on antibiotics so what we can do on the national side is now under debate and we will publish that and we will look what are the needed international steps that should be added chairman please can i speak up on um a comment francis made francis collins just made and that's around data there's no doubt the world's so-called experts know of this problem um but the truth is the the willingness to engage on this outside that group of experts we we've talked too long amongst ourselves and not enough with either the general public or or i think the policy makers if you look at the recent emergence of the ecoli resistance in in ashore when people have then gone back that that bug has been around for more than six years um and yet our data around the world has not been sufficiently in time and shared sufficiently and then the benefits of sharing that information sufficiently robust for allows to that if that had bug had been able to transmit easily between people it would be worldwide by now would be causing a major problem and that is going to happen this has to be the data around the world has to be uh shared and the benefits of sharing that data uh in terms of access to subsequent uh science and benefits has also to be shared but unless we know what's going on and we talk beyond the experts we won't be able to transform this great so let's make that a uh an objective for 2016 to get out of the ground initiatives and uh ourselves uh the Fleming fund from the UK uh the Chinese government are and WHO talking about now a global observatory where the data will be shared and i think that has to be one of the the critical things that we we move forward i think it needs a bit of a uh a push so that it becomes reality john you have the some reflections on this so no no okay you're at the same point please okay yes we debated it now in WHO in the EU in the G7 since in 2017 there is the G20 presidency in Germany so far G20 was not a debate on healthcare in general and if we see that we see there the uh huge developing countries with great agricultural sectors it's it's it's really a needed platform for combined things of the industrialized and the development pink countries the huge agricultural states so i hope that these G20 can also used to be an instrument for that i think it's absolutely crucial and it's only i think last year or so in in australia was the first time first time was there because of ebola but so let's make ebola the game changer for that because it has to be on where vaccines were mentioned also john you want to it's about introduction of new vaccines what i just wanted to answer uh you about some of your question i think it's we we know how challenging it is and then we we know what you know people are the different pharmaceutical industries going through uh the reality for us is and then we have to keep you know the global picture is 80 percent of the world is basically living in less developed countries so somehow we need to find things that works in those countries and so um and and acknowledging all the difficulty myself pitch on that is the fact that vaccines need to be adapted to some part of the world and then so we need to be adapted to the strain of where it is it's not the same everywhere the strains in africa is not the same that in asia or in the north in the northern hemisphere and the the other thing is it's it's needs it needs to be uh as well um uh thermostable because this is our challenge in africa and so one of the thing is is we we have to go and i know there's the the usual suspect would develop things but what we realize there's other industry that are able to develop and then and it's in in asia india and and and china just to take a few example and then msf you know for rotavirus for example we develop something that is the strains adapted to africa that is thermostable and then hopefully you know we'll we'll we'll go through the pre-qualification so but what what i want you to realize is is we may develop some things that is good for one part of the world but that might be a manner is like a fraction of the world and 80 percent of the world is in less developed world and so you need to develop as world tools that will benefit uh as well this part of the population because anyway it's going to backfire eventually so it's we we we need to look at the global picture so uh just to just to tell you that that's my take on vaccine yeah there's another dimension there and that's uh public trust believes in sound and that's in uh in in high-income countries particularly we have mesons epidemics in europe we had one in disney land so that got a lot of attention um there's yes there is there are children dying today in europe from vaccine preventable infections there's zero excuse for that it's a and but it's because of a lack of trust in then conferencing lots of things i i see that in my er all the time having to convince my parents to to vaccinate the children you see and and i just want to make one point you know set is gone for gavi i just want because ever since i was being portrayed that you know we don't like the idea of gavi and all that you know actually we love gavi to the next step the the thing is we just want to expand it to other countries that are in crisis that not only the low-income countries but today you know we are facing the reality that in the middle east we're going to be with a crisis that's probably going to last for a decade and then these are middle income country and they need to have access to vaccine at cheap price that's it that's that's that's we we want Syrian little children to have access to vaccine as well so not only important for the middle east but for the surrounding countries also i should i should say and coming back to my point public trust is this example of a human papillomavirus vaccine it's a vaccine that prevents cancer in japan today the coverage is below one percent it collapsed because of rumors because people think this causes i don't know what in girls and some besides then the whole paranoia side why is polio still not eliminated it it's not a technical issue it's because of war and of you know trust and polio work is being killed so i think it's again an area that you cannot address just in a technical fashion now we yes we uh we have i didn't know if you've fallen back in love together which is great but but i think we sometimes we sometimes become cynical about the ability of global organizations to pull things together in the modern world but just a very strong push for keeping the idealism that came out of the second world war those global organizations may not be functioning as well as they could but they still are a critical player to bring everybody together and make sure this is not just addressed through the narrow prism of national security but this is addressed through the prism of global health and i and i think we have to keep a sight of that idealism that came out of the second world war these organizations are needed more than ever in fact to bring us all together and gavi's a very good example of that no i i think your point is absolutely important and it's even there's even a stronger need and it's after world war two because the world is far more connected mobility is higher etc so there's no no doubt about that and and this year is the year of the replenishment of the global fund to fight htb malaria the the results have been spectacular it's rare that you can count so many lives saved and so it's it's a year there's a lot of demand on resources but that is crucial we have about good five minutes can i ask each of the my fellow panel members to what is your thought what what you would you like to see happening action this year in in terms to move the agenda we're not going to solve this in one year but what could we do this year who would like to start with that maybe it since you you have something very concrete today i think that we have to be aware that we don't make the same mistake as we did fault as we did 10 years ago so be determined to really make steps and it's very important to work together and to allow for example peer views not only between european countries because in the global health security agenda we also have peer reviews we also have that you sign up to help other countries to make their systems more robust and efficient and to help them to prevent for antibiotic resistance so i really think that we have a lot of actions and a lot of paper but i keep repeating come from paper to implementation that is really i think the core business for the coming year i would say last year the ebola crisis as a wake-up call made public global health a global issue we have to prove this year that this is not a one-year firework and that if we talk now about terrorism about refugees and all these things and some of them had much more common ground with these global health issues and people think about that we prove this year for example by taking our promises during the world health assembly that every state should have a national plan to go that way and this year is crucial to make it really a process so it is going to be a crucial year chairman i think my worry at the moment is that this space is too fragmented we've got the human sector we've got the animal sector we've got industry academia philanthropy etc i think if we're going to truly change this and it has to be at a global level we've got to rise it above microbiologists infectious disease people like myself and to a different level within the political discussion so that this is actually something owned yes at the level that climate change is owned at at the political level and if we don't do that we won't get the changes in regulation we won't get the changes of the human animal sector we won't get the incentives for industry and we won't get the control of use but also access so i'd like to see it raised above the level of experts to a higher political level and owned somewhere with accountability yeah very good yeah shuman well you told me that i asked to use sleep sentence but i know if i had to use buzzword i know for me for this year would be innovation for access is whatever we're going to do needs to be accessible and need to be accessible for everybody but of course you know jeremy said you know idealisms and msf we're full of the idealism but if we weren't there there would be a tough word so the thing is is is is i'm dreaming and i'm asking again for that rapid diagnostic test because i think it's going to make a difference in the the the less developed country but it would make a difference in my er in montreal and so i made that because i think it's a big driver and then i really do think that we need to agree on the trigger to how to help fail state when they all look facing a health emergency and and that we don't have to do that while it's happening so we need to agree before that what would be the trigger to come and help and not just to pass the buck you know like we're doing right now with the migrants we need a different model and then last i would just say that and i agree somehow with with jeremy when he talks about to portrait as a market failure actually there's not really a market failure per se with antibiotic because if we get the right antibiotic people would purchase it it's it's it's it's it's about for me is that more of of the same in that respect is the fact that the the it's it's it's all the model of of the market that's what we need to fix but it's not a market failure per se people's if we get the right antibiotic people's huge amount of needs andrew two or three things i think member states need to keep the voice that they've discovered at sinsebo and since germany's lead on the amr agenda i think that makes the multilateral agencies way more powerful multilateral agents can only go where the member states wants it to go and i think we've seen a lot of benefit from that but i really hope this doesn't just recede into yesterday's story and we move on to the next thing because like member states are really pivotal within this absolutely crucially you've got to start making some decisions i mean just we're going to go to a vaccine session right now i'm going to talk about a proposal on by a preparedness which we proposed a year ago we could have had three or four vaccine research programs into rare disease commissioned by now but nobody's made any decisions whether or not we should go forward or not now it may be a terrible idea in which case tell us it's a terrible idea and we'll stop talking about it or tell us it's a good idea and let's do it but i think we are we're in a mode at the moment where we're all saying this is super important whenever something specific comes up it that again it typically is being pushed into a sequence of well let's have a year's reflection on it let's send another working group off to talk about it and we're burning years up in this process we probably get there in the end but we're burning years up in the process so so i would really encourage member states to just be clear make some choices we're going to make some mistakes we're going to get some things right but we have to do some stuff so i think moving into that phase and i think really this conversation is really amplified how this is if you really want to get ahead of this it's it's definitely conservance it's definitely whole system agriculture as well as human health it's definitely prevention whether that's healthy living clean you know washing hands all of that and it's vaccination within vaccination to the question of how we move that forward is we need to understand there are modern vaccination looks different technically from traditional vaccination and somehow we as a society and regulators are going to have we've got to we've got to get ourselves comfortable with that step forward in technology and we've got to somehow try and achieve a standard which says we've ticked the boxes on this new set of innovation or not and if we have let's move forward but at the moment every new vaccine that's coming along is getting trapped in the kind of let's go back and recheck whether or not we're yet comfortable with adjuvant technology there was no new adjuvants for 50 years now we've got new adjuvants but somehow as a society and as a system we've got to get ourselves comfortable or not make the call or not but that's the kind of area where we should be focused i think thank you very much this is this is the end so let 2016 be the year of decisions and actions i think the roadmap is clear we have enough studies and working groups and all that so to and the hashtag would be it's not only about delivery of innovations but also innovation in delivery thank you very much