 Good afternoon, everyone. We're going to get started. My name is Joanna Erdman, and I'm the acting associate director of the Health Law Institute. So it's my pleasure to welcome you this afternoon to the Health Law and Policy Seminar Series. This is a series that brings speakers to the Schulz School of Law to chat about contemporary issues in health law and policy. You'll find a full list of our speakers on the HLI's website. And the seminars are always held on Friday at this time and in the spring. So this afternoon our seminar is co-sponsored by the Trudeau Foundation, and it's our pleasure to welcome Stephen Hoffman. Stephen is an associate professor of law and the director of the Global Strategy Lab at the University of Ottawa. He's an international lawyer who specializes in global health law, global governance, and institutional design. And I would really invite you to visit the lab's website. It's an absolutely incredible organization and especially for students in the room. It's fascinating to see the work that they do in the clinic. So I invite you to read up. So today's given is going to present, and you can see on the screen, on how the world can win the war on antimicrobial resistance, superbugs attack. He'll present for approximately 40 minutes, after which we'll open the floor for questions and theories. So, welcome. Oh, let me get that. Thanks. So first, thank you very much to the Health Law Institute. It's a joiner for the kind invitation, kind introduction, constants, and others who I've met during my visit here. It's a Dalhousie is known across the country for having the longest standing Health Law Institute. So it's quite an honor to be here and making this presentation today. So in presenting, I was asked to come up with a title that would maybe attract a bit of an audience, be dramatic. And I think I hope we did that. So superbugs attack, how can we win the war against antimicrobial resistance? The idea was that this is a real challenge that we are not seeing enough action for. And so there's a need for a lot more attention. We're starting to see some of that. But then attention isn't enough. We actually need some real action to make sure we can address this challenge. The challenge in my mind starts actually not in today, but a long time ago. In hundreds of years ago, so this is a map of the spread of the bubonic plague across Europe, 700 years ago, you can see that we would measure the spread of infectious disease by the basis of per year. So the different color represents a different year as it's spreading across Europe. Now in a world where the spread of infectious disease moves like this on a year-to-year basis is very different than what we have today, where literally in 24 hours we can get anywhere in the world and carry bacteria and viruses with us. So this would be a map of the flight patterns that we see globally, along with cases or outbreaks of infectious disease that happen along the way. And as a result we get scary outbreaks. The most recent one that was officially declared a public health emergency of international concern was Ebola, broke out in 2014 in West Africa. That's caused quite a bit of attention given it was an outbreak of something that typically happened in one area of the world, it's a very poor area, Sub-Saharan Africa. And you can see in here that the cases were pretty localized and different outbreaks over the previous 40 years. Suddenly we have infectious disease spreading though. We live in an era of hyper-globalization, hyper-travel. And so this really got the world's attention and spread to many different countries, rich countries, which then made sure there was quite a bit of political attention. And the world went crazy. And so infectious disease, we live in a different world where it spreads. It's very difficult to stop that spread. And we also know that when it comes to us, we care. And so we cared about Ebola. Today we're talking about Zika. And on Monday the WHO, the World Health Organization, is convening an emergency committee to determine whether this is the next public health emergency of international concern and whether we should be having any sort of travel restrictions or anything. So this is something that happens commonly. And it's something we need to be watching out for in a more systematic way. And with Zika, this is just from the economist a map showing where there are currently cases of Zika virus and then where it's expected the areas that could be at risk. So we live in a country where fortunately at the moment we're not really at risk given the 80s mosquito which carries the Zika virus does not right now live in Canada, nor in Chile, but the rest of the Americas is at risk as well as the many other countries in the world that have it, that particular mosquito. But today I'm not talking about the classic pandemic in the sense of the ones that are really loud and that we're talked about a lot in the media and that spread really quickly and easily visible ways. I'm talking about the silent pandemic of antimicrobial resistance which some people call super bugs. And unfortunately the super bugs is not cute and cuddly like our super bugs bunny here. Actually it's quite terrifying. And the reason it is so terrifying is that it's something that is happening under the radar for quite some time and will continue to happen. And the reason I say it will continue to happen is because this is a natural phenomenon. This is really bacteria and viruses evolving in response to its external environment in the same way that humans have evolved over time in light of its external environment. And so here's a try in terms of antimicrobial resistance 101, the science of antimicrobial resistance to simplify one way that this happens that bacteria and viruses develop resistance to existing antibiotics and antivirals is that they naturally develop that resistance in one. So let's say there's trillions of bacteria in the world. By natural random chance one of those bacteria, well many of those bacteria are going to develop some sort of resistance to a drug that currently would kill it. And for example one way is drugs often will be effective in killing bacteria for example by let's say blocking or by getting through a protein channel. So there's a cell, the drug would travel through a protein channel into the bacteria and then that bacteria would die. Now what if the bacteria by random chance happen to have defective protein channels? So suddenly an antibiotic can no longer get through. Now in the absence of antibiotics this would be a defect. This bacteria would not survive very well. It's defective, it has a defective protein channel. It means all sorts of good stuff also can't get in. But in the presence of antimicrobials, in this case in the presence of antibiotics, ones that usually kill bacteria, we have a situation where actually the defect becomes their super strength. It's their super power. Which then means that they out compete other bacteria and they proliferate. So it's a natural process of antimicrobial resistance, it happens naturally. But our use of antimicrobials actually significantly speeds the development of this resistance and is what allows it to really proliferate and spread globally. And so here just to show the visualization you can see that here we have one bacteria that's not resistant, one bacteria that by random chance let's say develops the resistance. And then in a world without antibiotics, mostly the ones that win are the ones that do not have the resistance because they're not defective. But in the presence of antibiotics, so when we take antibiotics, let's say in a hospital setting or in the community, we kill the bacteria that are still susceptible, leaving the other bacteria that are resistant to be there to stay. And then as a result they then out compete and they multiply and go forward. So this is a natural phenomenon which all of us contribute to, which humans contribute to. And so just to highlight the extent to the problem, you'll see that there's in a clinical setting, we often will rely on antibiotics in order to improve our health. Much of the health gains over the last 100 years have been because of antimicrobials, including antibiotics, antivirals, antifungals. So they've been enormously successful in allowing us to live longer and healthier lives. But it comes to the point where often we use them when they're not actually helpful. So on the left you'll see this figure, this infographic, which is showing that for adults, these are US statistics, which maybe would be similar than in Canada, adults who visit the doctor for a sore throat. How many of those people get prescribed an antibiotic? So usually a sore throat if it presents itself, a doctor probably won't know what it is. But they do know statistically 10% of people who present with a sore throat, it'll be a bacterial infection, whereby antibiotics could be helpful. 90% of the time, it's not. And so 90% of the time would be when patients come, it would be inappropriate to prescribe an antibiotic. But what percentage of times do people who present with a sore throat get prescribed an antibiotic? 60% of the time. Which means assuming that all the 10% of people who actually needed the antibiotic or would benefit from the antibiotic, at the very least an additional 50% are getting it. An additional 150% of people are getting it when it's not needed. Or in other words, 6 times as many people leave the doctor's office with a sore throat, with an antibiotic, who don't need it, then who do need it. So that's a problem. And it's not global, but it's also a national problem, because you see in the right figure that those countries that use more antibiotics are also those countries that have the presence of more resistant bacteria. So this figure, specifically on the bottom, is if you're the countries that are further to the right, like China, Spain, and France, the people there use more antibiotics on a per capita basis. And then up on the vertical axis is the percentage of pneumonia-causing bacteria resistance that are resistant to antibiotics. So in China, over 50% of pneumonia-causing bacteria are resistant to antibiotics. So don't get pneumonia in China. But also don't get pneumonia in Spain, France, or in the United States. So it's a very scary thing, and the link is quite clear. And it's not just doctor's faults. So this was a study done, a survey done in the U.S. and this looks at how sick patients are often actually insisting on getting an antibiotic for their sore throats and other things when they leave the doctor's office. So 55% of doctors said that they were pressured in order to prescribe an antibiotic. So that statistic, getting pressure, that's not good, but that's okay. I mean pressure's okay if it's not having a health implication. But what is going to have a health implication is that 45% of doctors in the United States admitted to prescribing an antibiotic for bacteria when they thought it was a viral infection. 45% of doctors admitted that they gave a treatment which then breeds resistance when they knew the treatment was not going to help the patients in front of them. That's crazy. And what maybe contextualizes it and explains it is that 44% of doctors said that they prescribed an antibiotic to get the patient to leave the room. So we're all part of this problem. It's not just humans. As much as we can talk with humans and we would want to focus on humans because the transmission of resistant bacteria or viruses between humans would be most easily happen. But there's also a process called Zoonosis whereby we get disease from animals as well as some of the bacteria that affect animals would also affect humans. And so this statistic, which is again for the U.S., the global statistic is 75%, but the fact that most, the vast majority of antibiotics are currently used for animals is quite a thing. And in many cases, this use of antibiotics in animals is not because the animal is sick. If so, that's important, right? Animal welfare, ethics, if an animal is sick and we can make the animal better with an antibiotic, great, and we should give it, and a veterinarian should be involved. But really what the greatest use of antimicrobials, specific antibiotics in animals is for the fact that it allows farmers to keep animals in closer conditions whereby they live closer together, which on one hand would facilitate the spread of disease, but if they then give lots of antibiotics in a prophylactic way, such that even healthy animals, if they give antibiotics just en masse, then the risk of transmitting disease among animals in close quarters is lessened. But the alternative would be just to give animals a bit more room. The other use is that there is a side effect to antibiotics, which is that when they're consumed an unintended side effect is that they bulk up. So actually giving antibiotics to animals currently is cheaper than giving animals more food. And so in some cases, antibiotics are specifically marketed and used in order to save on food costs. Yeah. Another interesting application of antibiotics is the use in products. We often don't think about this, but this is a material health and safety data sheet for the use of an antibiotic paint for ship hulls. Now Halifax is a port, and I know that ships are built here, so one use of these things might be to actually paint a ship and maybe in the hull and to make sure that mold doesn't develop. So that actually, that sounds like that's a good use, but maybe not. It is a use, and we have to think about whether it's a high value use. I think what's clear though, a good example, my favorite example of what's crazy about this is when we use antibiotics in order to promote unhealthy practices. So this is a list of those antibiotics that are registered for use in plant agriculture in the United States. So it's a long list of lovely products, which I enjoy, and then it gets to the bottom where there's a product I don't enjoy, which is tobacco. I know it's small, apologies, but it's in yellow there. Tobacco, which there's a disease wildfire and streptomycin can often, can help reduce the presence of wildfire in tobacco. And as a result, tobacco plants get sprayed with streptomycin. The same drug that helps keep us healthy when we get sick is what is helping keep tobacco plants more vibrant so that they can be sold to more people who could then get cancer from it. So at the very least, we can probably all agree that this is a low value use of our streptomycin, of our antibiotics, which then, in turn, breeds resistance and makes it so that the next time when we get sick and we need streptomycin or another antibiotic, it's not as effective for us. So that's, this is bad. In terms of the statistics, a lot of people are already dying from antimicrobial resistance. So 700,000 people are currently estimated to die worldwide because of superbugs. But it's not just 700,000 that we need to worry about in the future that this problem is exponentially growing given increased use of airplanes and given the increase in use of antibiotics around the world, as well as the fact that we haven't been successful in developing new antibiotics, which would then be, come in, replace the old ones that no longer work. And so by 2050, there's the expectation that 10 million people per year will die because of antimicrobial resistance. And just to note what you'll see there on the right-hand side in the graphic, on the left is the deaths from antimicrobial resistance that are expected in 2050, so 10 million. That exceeds the expected death toll from cancer. It also exceeds the expected death toll from heart disease and from stroke. So basically, antimicrobial resistance will be one of the most defining health challenges we face over the next 100 years. And if we don't take action in most of our lifetimes, we were going to see a lot of people die from this. And the challenge is that often when we see people die, we don't often label it as antimicrobial resistance. There's a bit of a PR problem with this challenge. When someone dies from an infection, we call it an infection, we blame that. We don't usually say it was resistant to the drugs that we tried to make it for which we tried to address it with. So there's no disease face. This is actually a problem across public health. There's a foundation for most diseases, a breast cancer foundation, heart and stroke foundation. There's Alzheimer's, and when people get something, there's a foundation, there's a lobby that's encouraging action, which is great. Unfortunately, there's no face for this problem. And people don't usually know when they actually die from it. So there's a PR problem that needs to be addressed. Unfortunately for us and unfortunately for the world, we can't address this problem within our own countries. We in Canada could do a lot to address antimicrobial resistance. We could do a lot more. We're not doing enough. But even if we spent every health dollar that we spend, if we spent it on addressing this challenge, we still wouldn't be able to solve it, because all it takes is for one flight of one person flying, carrying with them a resistant bacteria or a resistant virus, and then it comes to Canada and then it can spread. So we need to do more. We should be doing more. But this is not a problem that can be fully addressed by individual countries acting alone. It's a global challenge. And so this is one example whereby you see the resistance movement is the title of this from a Nature article. It started, this is from an enterobacteria that's resistant to carpapenem. Carpapenem is a drug that many of us, probably most of us in the room have never actually used. It's a last resort antibiotic. It's an antibiotic that would currently be given if the other antibiotics don't work. And yet this is a bacteria, the enterotera bacteria, initially resistance was developed in India where carpapenems are widely available because there's no physician prescription systems in India, given there aren't enough physicians, so that's understandable. But they're highly used in India, resistance developed in India, and traveled internationally. And it's not just, I don't just blame India, there's others that start in different places. And so there is a global movement of these things. We know that this travels. And so here's a study just came out a couple months ago in the Lancet, which, this is the same map that I showed at the beginning with the airlines, where I showed different cases of outbreaks of various things. Here is the same map, but this time these are outbreaks of resistant bacteria, specifically for that carpapenem, resistant to carpapenem, that last resort medicine. And so what you'll see is it tends to happen where there's travel. Halifax has an international airport. Halifax is also at risk. So the superbugs are coming, the superbugs are coming, the sky is falling, but yet we aren't seeing the necessary level of action. And so in my own research, a lot of my work has been about, well, why aren't we seeing the necessary level of action? And what kind of action do we actually need to address this challenge? It's clear that, yes, we need more medical research, yes, we need to understand the biology of viruses and bacteria, but there's something else here that requires additional efforts and there's clearly some global governance and global market failures that are at play here, which is allowing this problem to spread so quickly and become such a challenge. And so just to simplify, to convey this as easily as possible, I think of this problem as a three-part problem. So antimicrobial resistance, it's a challenge, and I think of it specifically as a three-pronged challenge. The first challenge is conservation. We need to conserve the effectiveness of our existing antimicrobials. If it's too fast, our antimicrobials are becoming ineffective. That's a problem. The second thing we need to do is promote innovation. In 20 years, we have not come up with a new antimicrobial antibiotic. That's a problem. It means that we're dependent on old medicines that have over the last decades have become ineffective. Now, there's been some tweaks to some of these medicines which have made them more effective or different contexts, which is great, but there's been really a wholesale lack of innovation in this area, which is a problem. And then the third prong is access. Currently, more people die from a lack of access to antimicrobials than who die from antimicrobial resistance. Now, that will likely change. By 2050, more people will die from resistance than from lack of access. But currently, there are millions of people who mostly in the poorest countries in the world who don't have access to antimicrobials and as a result, they die or suffer all sorts of range of consequences. And the challenge, though, is that we can't just think of it as a three-pronged problem. We need to think of it as a three-pronged inter-linking, interconnected problem. Because unfortunately, we can't actually address each of the prongs individually. We need to do so in concert. And the reason for that is that even if we provided, if we provided access to lots of antimicrobials to people everywhere, whoever needed them, the problem is if we don't do it with conservation and we don't do it with innovation, then we just speed resistance. We actually just make our problem even worse. We also can't just focus on conserving existing antimicrobials because then we actually would be further constraining access, which means the millions of people who currently don't have would have even less access. And also, it actually undermines innovation because by constraining access, we create a smaller market. And if there's fewer people who are going to buy a medicine, for example, because we only allow it to be used for different contexts, then industry is far less incentivized to actually develop new products which they want to sell to many people for as high of a price as possible. And third, we can't just focus on innovation, which frankly has been our approach for the last 70 years, well, with the last two decades excluded, but our approach used to be we would just invent a new drug, a new antibiotic. The problem is that innovation without access is just unjust. And innovation without conservation is wasteful because what it means is we spend all this money inventing something new and then a few years later, resistance to that drug is present. So what underlies global, inadequate global action? For me, it's two things. It's the global governance failure in that we have a classic collective action problem whereby every state would be incentivized in order for everyone to together address the problem, but each state is individually incentivized to deviate from enacting expensive policies because of various challenges which I'll discuss in a second. So it's a classic collective action problem. Think climate change. Climate change is an equivalent example where there's this global problem. We would all benefit if we all took action to address it, but we all are not taking the necessary level of action partially because we're all depending on others to do so and others deviate and we deviate. We particularly don't look so great on climate change. But in terms of the global market for antibiotics, there's also failure there in that we have the under-provision of this product in the poorest countries in the world. We have the over-provision of this product in all countries for people that were using these drugs when they're not helpful. And third, there's insufficient innovation. So there's an innovation crisis in this particular area and that's the market is not inset. With current mechanisms like patents, it's an insufficient incentive for industry to invest in innovation, which really points to the need for this. If this is a public good challenge, we probably need public funding for it. To be more specific, there are very concrete game-theoretic problems that are at play here. So game theory is really all about looking at strategy as to why actors behave in different ways from an economic perspective. And so if one looks at the challenge, as I'll explain here, it's actually kind of rational that countries are not taking action at the moment. I say that, I think that's very unfortunate. But I would say the same thing for climate change. It's a bit rational and self-interested that, for example, Canada hasn't taken such great action on climate change. And for various reasons. And I would break it up, though, that there's different game-theoretic problems for each of the three prongs that are part of this challenge. So let's start with innovation. In the case of innovation, why would a country like Canada want to spend lots of money on innovating for new antibiotics if we can just wait for the United States to give that investment instead? And in fact, that's actually what we do. We free-ride. It's a free-rider problem. We free-ride on the United States and Europe in order to, we depend on them to develop drugs and then we use them. Which is, yeah, we benefit from that. But everyone does that. And as a result, there's insufficient levels of innovation. The other challenge is that how do you manage innovation? So these innovations are global common and it's very difficult to put restrictions on their use. Yes, there's patents. So legally, these innovations are not, you can only use when the owner of the patent, for example the pharmaceutical company, would sell it. But there's so much counterfeit medicine that it's a very difficult for even the owner of this intellectual property, of this innovation to effectively manage it because of, well, once a patent is put up online, it can be reproduced and drugs can be remade. So it's a big challenge. In terms of conservation, we have the same very similar problems. So in this case, there's some unrealized positive externalities of investing in conservation efforts. So for example, even if, let's say, a country in Africa, each country, or at any country, each country would benefit from conservation efforts themselves, but also countries around them, or any country where people travel to and from those countries would also benefit. So for example, if our hospitals are asked to take greater infection control prevention measures, that's expensive. So we would be paying the cost. Canadian taxpayers or Nova Scotia taxpayers would be paying the cost of improving infection prevention in Nova Scotia hospitals. But New Brunswick would also benefit, and so would the United States, and so would anywhere where people come from to visit Halifax and other cities in this province. But yet, the total cost is born by Nova Scotia. So what that means is that the full value of these are not reflected by the people who would usually pay for them. And so there's a mismatch between, it means there's unrealized positive externalities that we're not achieving. There's coordination problems. There's also, again, global commons dilemmas. And then in terms of access, we have this challenge whereby on one hand we want to promote access to medicines around the world. There is a global injustice happening and there's a lot of attention on this. The challenge in terms of antimicrobial resistance is that if we promote access, in some ways it could actually contribute to a negative externality, which is the development of resistance that can then spread internationally. So the need is not just for access, but actually appropriate access, which costs more than just access. And as a result what we see is here's a little bit of a mapping of the different actors globally who are responsible in doing work and it's a bit of chaos. That's what this figure is really supposed to be if instead of the actors I could just write the word chaos. This issue has been known for a long time. For 40 years the World Health Organization has been passing resolutions, drawing attention to it. So it's not that global action is absent. It's that it's both insufficient as well as not very well done. And so specifically there's four key challenges. The regime gaps. There's gaps in this global governance regime. One is coordination. Each actor sort of does their own thing. Two is compliance in the sense that even actors that say they're going to do something, the follow through is a different matter. Third is leadership in that there's really at this point no actor that's really carrying the flag to make to coordinate actors and really raise political priority. WHO has attempted, it's maybe not in the best situation at the moment to do so. And fourth is financing. Up until very recently there's been just a lack of money in this area. Other health issues have gotten the priority. And so as a result countries including Canada haven't been taking the necessary level of action. So even in Canada being one of the richest countries therefore we shouldn't be expecting the world's poorer countries to take action either. So this was a report from the Auditor General just in May of 2015. So not even a year ago. When the Auditor General reported that the Public Health Agency of Canada and other government agencies have not fulfilled key responsibilities to mitigate the public health risks posed by this challenge. The report was if anyone here has ever read an Auditor General report they're usually pretty measured and balanced pros and cons. Government always has an opportunity to comment and provide feedback along the way during an audit. This was pretty pretty stark, pretty dramatic the language that was used. In no uncertain terms the Auditor General let us know that our country is not doing what it needs to be doing. So if we're we're one of the richest countries in the world if we're not taking action then well that explains why nearly every other country is also not taking the necessary level of action. So we're in this war battle of our bodies where bacteria are fighting and on one hand we have bacteria that are causing us ill and harm and then our antibiotics well they're not doing so well in this fight given that we haven't replenished them but also we're abusing them. And so the question in my mind is then what do we need in order to address this challenge? What's the solution? I presented up until now all the problems but what can we actually do to solve this problem? And so for myself and several colleagues we've come to the realization that because there's action that's needed it's needed to be global and interdependent that maybe this issue unlike many other issues maybe this issue actually requires an international legal framework in order to address it. Maybe we need a treaty on antimicrobial resistance. And so this was an editorial in the Bulletin of the World Health Organization where we called and tried to make a case for maybe of all the health issues out there maybe this is the one that actually would benefit really benefit the most from an international legal mechanism of some sort. And so why international law? Well what we've argued is that there's some things about international law that only international law can do or that there are certain problems whereby international law is uniquely placed to try to address it. So for example this problem is that there's interdependence between countries. So in order to solve the problem all countries need to act in order for any country to be safe. That seems like a good use of international law. The second is that there's interlocking actions needed meaning that some countries might want to take action on some of those prongs for example some countries care more about access and other countries would care more about innovation but to solve the problem we actually need to address all three. So what it means is because there's interlocking actions needed and we actually need everyone to do all three we need a mechanism that can commit where states can commit to each other. That's international law. The third is that actions are costly which means that no party is going to want to do it their own actions unless there's the strongest possible commitment from others that they're also going to do the same and they're also going to incur the same costs. So our international system is relatively a weak system but international law is the best we have in terms of the strongest way states can make commitments to each other. I know it's not perfect there's lots of people who discuss in good ways whether international law has any effect at all. I'm an international lawyer I do believe international law is important but in this case even if it's not 100% effective it's the most effective thing we currently have. And the fourth is that international laws are really long-term instruments and in this case because our short-term incentives to deviate from collective action are contrary to our long-term incentive which is to cooperate it means we need a lock-in mechanism. International treaties provide that we can lock in countries and then actually through a treaty disincentivize deviation. And so what we really need super bugs to win this war on super bugs is institutionalized grand bargain. What could that grand bargain what's needed as part of that grand bargain? Well there's at least two sets of things that are needed. We need contents of an international treaty so we need what are those policies or those regulations that every state is going to agree to do. And so as I've mentioned we need to think about access conservation and innovation. We need policies for all three. Every state has to commit to doing stuff in those areas. But just committing is not enough and that's the problem that people often talk about with international treaties. Lots of talk, no action. And so one of the key things that we need to make sure is that that doesn't happen with this. And so one way to do so is to build in strong implementation mechanisms whereby we build institutions that encourage, that rally countries together and help make it easier for countries in order to comply. We have incentives either positive or so character sticks to ensure that countries stick to their promises. And third, interest mobilizers so advocacy and lobbying related efforts supporting that. And so myself and colleagues have started to do work about what would the content of an international treaty look like on this issue. Here's a picture of an article that was published three months ago in the Lancet Medical Journal that really starts to lay out where are the key areas where we need international cooperation. And then in terms of implementation mechanisms more recently just a few weeks ago the Bulletin of the World Health Organization published this study of mine which we suss out what are some of these implementation mechanisms. So how do we build institutions? And so in terms of first I'll have a content and then institutions in terms of content what we've been saying is that we need on conservation there's about seven policies that all countries need to commit to doing. So one is that is the prohibiting the use of antimicrobials for growth promotion or routine prevention in animals. That was that we need countries to ban industry to ban farmers from using it for low value purposes. If animals are sick of course they need to be treated. But simply to use antimicrobials as a way of reducing food prices so that we don't have to feed animals as much that should be illegal under international law we think. The second would be regulating antimicrobial prescription and availability for humans so right now in Canada we already have this so if we need an antibiotic we have to go to our doctor and we have to get a prescription and then we go to the pharmacy and it gets filled. In many countries where there aren't enough doctors and aren't enough pharmacists and other health professionals antimicrobials are available much more broadly sort of at the corner store. Now to demand a doctor's note for prescription would mean the death of many people and the effect of illness for many people in many poor countries. So we need some way it's not necessarily prescription but we need some way of regulating the use. And third at the very least we need to regulate the use of certain types of antibiotics. The new last resort medicines those really need to be make sure that we we only use them when needed and that includes never using those in animals. Fourth we need to improve surveillance. Fifth we need to promote education on the effect of use so that people the 65% of people aren't demanding or aren't pressuring doctors to get an antibiotic after they when they have a sore throat. We need to strengthen infection control practices and then we need to prohibit marketing. So in Canada we don't have direct to consumer marketing of our drugs but in many countries pharmaceutical companies are actively have billboards and posters promoting people if you're sick take get this antibiotic and in a country where there's a doctor the doctor can be a bit of us adore in terms of stopping like yeah you see that that marketing but it's not needed for you but what about in a country that where you can get an antibiotic on the street or in a corner store if you see the ad you might just go get it so that should be illegal as it already is in Canada. And then we need content on access and innovation I see I'm running out of time so I'll speed up but in terms of innovation we need public funding and incentives for private and public innovation. This unfortunately this problem with our current market structures the way patents work the way pharmaceuticals are regulated there is insufficient private incentive to develop new drugs and why would a company develop a drug that a government is then going to restrict its use on only allow you to sell it to very few people put caps on costs if I would not be investing in a pharmaceutical company that only develops antibiotics at the moment but if there is public money that went to it to create a public good that was then properly conserved then we could finally see innovation and hopefully any public dollars are linked to access provisions to make sure that all people get access we need to mobilize financial resources for infrastructure so poor countries in the world realistically are going to need support from wealthier countries to develop surveillance systems so that we can track viruses and bacteria as they spread and we need funding for access I think this is a key in that we need to make sure that poor countries are not just instituting measures that will be helping out expensive measures that will help conserve existing antimicrobials when they then don't have access to those very same antimicrobials in many contexts so there needs to be a bit of a balance there in terms of implementation there's many things we can do to promote to make sure that the value of the treaty is not just the ink on the paper on which it's written or the keyboard on which it's typed but actually it has an impact so we can establish monitored milestones we can have a code of practice we can have an interagency task force coordinating UN actors or we can create an intergovernmental panel like we see in climate change where there's different scientific working groups and regular reporting we can have incentives so we can link compliance with this treaty with access to funding we can create a global pooled fund in order to finance efforts towards being compliant we can condition benefits and supports and then in terms of mobilizing interest we can task special representatives to rally the troops we can have a high level panel to bring political attention to the issue and we can develop multi-stakeholder partnerships that try to bring states and non-state actors and industry all together to try to solve this challenge so to conclude it's clear that we cannot just tackle the biological and clinical manifestation of this challenge we need to do that too we need more research on biology we need better clinical practice but we also need to tackle this difficult global political economy of inaction and in my mind and for many people in a growing number of people around the world we're starting to think that an international treaty could provide legal protection against this challenge that currently is risking all of our well-being now and in the future thank you thanks so much Stephen so we have plenty of time for questions, comments discussions I hope I didn't scare everyone human rights element of this that's a great question so what roles does vaccination play in terms of addressing this challenge an infection that's prevented is one that doesn't later need to be treated so it's reducing the demand and need for the use of antimicrobials and it's not just humans it's also in animals so in Norway for example all fish need to be vaccinated it's a thing yes, Norwegian salmon if anyone enjoys that it's vaccinated which is good the challenge is that we can actually do quite a bit that when we see that antimicrobial resistance it's a natural process we need antimicrobials are going to be used we want them to be used when they're going to be effective so if we can just lower the number of times when we actually need to use them hopefully we'll then use them less and then have less resistance your products that has antimicrobial in it like your hand soap and anything that's right so there's debates about whether we should be using those at all so I'm not a physician I think my understanding is that there's a bit of nuance some of the products are maybe higher value use others are really not I know there's nuance in that but it is an interesting development I think it's more the labeling that's being used by companies to sell products it's the same way I mentioned in my talk I talked about the antibiotic formula for paint I'm not sure how effective that would be the paint but maybe it's I think we need to put the big question we have to ask is what are high value uses of antimicrobials and then how do we ensure we are only using these products for high value uses the tobacco example of spraying tobacco fields that's the best example of a low value use which should clearly be illegal on the human side I'm surprised you haven't spoken about the role of patients I think you've overestimated even a sophisticated like you have overestimated the value of penicillin for sore throats and the interest of patients and your interests are aligned when people don't take drugs that are useless or harmful so why don't we have a regulatory framework where there's an insistence that the drug packaging include information about members needed to treat members needed to harm and I imagine even in this group where probably everybody has taken the drug very few people have asked when they received the drug how many people are healthy how many are healthy in your example which is a specific example of a general problem of overprescribing in Canada a labeling requirement saying you have a 1 in 100 chance that this will help you most people would ask more about am I the one who is likely to be helped or not and you may not even need a large framework to do it just a simple comment the way we have nutritional contents foods have something about the drug should be given to people so you asked for the role of patients and the role of labeling medicines and the risks or the potential effectiveness how helpful that might be I don't know how many people read the existing labels on medicines I don't they're not useful if they say this drug may kill you or this drug may help you and the real question is if a thousand people take it how many are killed how many are helped and the labels there's no point in reading them because they don't provide the information that you really need which is a quantitative one when a patient is taking a drug and making a wager that the benefits are more likely to outweigh the harm that's right so I guess you have a lot of faith in a patient's ability to understand those kind of statistics you have a simple thing if a hundred people take this drug one will benefit 99 won't 10 will be harmed I have faith that most people will understand yeah at least the people in this room and they will tell their friends who may be less sophisticated yeah I mean even if so let me so you've said that we if people are given the information maybe they would act better in this but from a self-interest even if that was the case I'm not sure I agree but even if it was the case from a self-interested perspective people are still maybe incentivized to take an antibiotic if there is a one in a hundred chance it's usually more like let's say a ten a one in ten chance but that's right cause the consequences adverse events they have to have the harm from the benefit yeah but I know I'm not I'm not convinced and also the self-interest cause remember the consequences of us taking an antibiotic when it's not needed are not fully born by us the greater cost is to the population it's to everyone else so we are personally a bit self it's a it's rational for us to consume it even if there's let's say a ten percent chance of it working because the risk is born by everyone not just us I should probably just ask that we keep moving yeah we have time new conversations just to that matter but the issue with that type of thing also is that health literacy and people that have access to to actually understanding those type of things even if they move the bottle the chance that someone will understand what that bottle is saying you know for most people don't have access to being able to understand that type of stuff assure your doctor could explain to you but sometimes you know they're speaking another language to the average person so people like us who actually take it interesting these type of things they it's more understandable so I think what the gentleman is saying is that although we may label things you know some people don't pay attention to those labels they'll still power feel you know just like if you go into the supermarket and you read a label of a food box most likely if you don't have access to anything matter you're going to pick up that food box and buy it in there's a bag if I can jump in right after that great yep well personally speaking I take powdered Chinese herbs when I'm sick and I find them very effective and I haven't taken antibiotics for about 25 years and I also eat again food and that means it's so difficult speaking of that and so I'm just wondering if people in that kind of zone said if they were to become ill and needed antibiotics would that be more local unfortunately no because if the infection that's someone who so the question is whether someone who doesn't take antibiotics and uses alternative methods or eats organic food and doesn't use this antibiotics so it isn't exposed to antibiotics whether when they do have antibiotics would they be effective it depends on the infection if the infection is caused by a bacteria that has resistance to drugs then yeah just this resistance that's right but you mentioned organic food so since I've done work since I started doing work in this area I personally now only eat antibiotic free meat it's not for my own personal health because during the last 90 days of an animal's life farmers are already not feeding them antimicrobials to wash it out of the system such that the actual meat that I eat the antibiotic free meat or the regular meat none of it has antibiotics in it or none of it should legally but by me I decide that there's an opportunity to reduce the market demand for farmers to do a practice which I'm hoping they won't do I think the real we really need regulation we need bands on the use of low value the low value use of antimicrobials and animals but so I follow that practice from a population perspective there's someone here yeah thank you very much for this very important presentation because there's another side of antimicrobial resistance and we usually focus on the human side so thank you for that so education I really see is the key piece in the strategy in educating people about patients or people knowing about it and reading the labels usually when prescriptions are given by the time they get their prescription that's the time and then actually come to know about the medication and issues and side effects and all of that so a step back even before they're prescribed is where the education needs to have my question really was about the access piece in the third world countries could you spend a little bit more on how that will help balance the equation yeah so for example one so the question was about the role of access or lack of access to antimicrobials in developing countries so one so 200,000 neonates die each year because of lack of access to injectable antibiotics lots of people die from a range of diseases that we have from pneumonia and other things that really we can mostly prevent already if they had the same diseases infections in Canada so the need for access is right now an enormous global justice imperative and the lack of access is the global injustice at the moment the challenge will be going forward that efforts to promote access to medicines which I strongly support and we need to do they need to do it in a way that's pairing access to antimicrobials with their conservation at the same time what we need is not access to medicines we need appropriate access to medicines and so doing that is unfortunately more expensive than simply promoting access to medicines so already groups like there's an agency called the Global Fund to fight AIDS, TB, tuberculosis and malaria that agency is a global pooled fund they already take action on this and that they fund diagnostics for things to make sure that the medicines that it pays for in the poorest countries are hopefully being used as appropriately as current technology allows there's also increasing emphasis on developing diagnostics that can actually detect okay this person has this infection which to which antibiotics is it susceptible so which one of the let's say six different kinds which one will work on this particular patient's case now in mostly diagnostics we think of it's a lab so you take a blood sample or a swab you send it to a lab you get the results the next day and your doctor might give you a call saying yeah take antibiotics or don't take them in most developing countries so labs not very many the 24 hour delay is a problem because will people will they be will the doctor if there is a doctor be able to reach their patients and then if they the doctor says yes let's take your medicine can the person afford to buy the medicine that they need rather than the cheaper one that the pharmaceutical company is advertising to end promises that will work whenever they're sick for anything so there's lots of challenges sometimes in the interim that they get the results back they put the person on an antibiotic anyway and then they switch over to another patient also probably yeah so I'm not so in terms of treating someone on an antibiotic before knowing for sure if it's susceptible so I'm yeah I'm not a physician I'm sure under many circumstances that's appropriate and maybe under also under circumstances it's inappropriate I don't I don't know but Janice sadly you know some of these work in in low-income countries and in the continent of Africa and close quite closely with the WHO in the last 700 years appropriate has been taken up by all sorts of gamers okay and it's almost become a gloss for the lowest cost and the lowest cost ends up being something that is gained into an agro-business at a big pharma advantage I'm working on a paper right now that shows that and it's really a problem and I mean I see you know I just checked out and it's all very fine and well to talk about the governance but even in Canada we know these policies are you can sit down and write them drop them now and whether it's a liberal government or a conservative government the chance of getting them through until there is the major the major international and you know pandemic type of event it's not going to happen I have a bit more so you've asked what's the maybe you've asked the political feasibility of actually getting traction on this issue in the short term I am so yeah it's a bit depressing my talk is mostly depressing but I should have ended in fact next time I give a talk like this I'm going to end on a positive note which I think we do there is something that's happening to of the last couple of years last 18 months we've seen a lot of the last G7 meeting in the communique they talked about anti-microbial resistance as a great security threat that needs to be addressed billions of dollars have gone into this new billions of dollars I guess a couple billion dollars but that's still the right number of zeros in terms of addressing this challenge this September there's going to be debate of a UN General Assembly resolution basically that's acknowledging that it's not just Geneva that's in the foreign policy people in New York that have a role to play in terms of in Canada for a decade we had a federal government that did not believe in federal leadership on health issues so most health dollars in Canada would be spent appropriately so at the provincial level given hospitals and physician services and drugs are mostly coming under provincial jurisdiction given our constitution in that area of health and for a decade we had a government that didn't believe in federal leadership but unfortunately on antimicrobial resistance it's a challenge that provinces can't actually address on their own yes they can do the clinical part of it so promoting hospital infection prevention practices trying to reduce the physician prescription advanced botics provinces can do provinces could not regulate the same way that the federal government could have tracking resistance diagnostics so now we have a new federal government that has shown through discussions around the health accord for example that they are not only willing but actually they want to take a federal leadership role on health issues antimicrobial resistance would be a natural one whereby it is one of the only health challenges that we can only address in Canada if the federal government takes leadership there is such a business case there is political momentum for the federal government to do something there is that auditor general report that was so damning maybe the question of your business case in the Africa and the World Health Organization and with our federal government I would already the liberal government before the Conservative government let us down with the billions of dollars because those billions of dollars are already identified and be earmarked by a few of the groups that are actually causing this problem that's right and hopefully Canada can increasingly contribute to those that amount of funding it's it hasn't been a priority to date it's my politically correct way of discovering you talked about funding into where the money is coming from briefly I'm just wanting to talk a little bit more about that because there's the other side of access that I'm concerned about not just having access to microbials but what about when you take away antibiotics the food gets more expensive organic for example is a very expensive and on one hand this is talking about stopping a problem that we're going to have very soon on the other hand I still see this huge problem with the other end you know yes I definitely wish we could add even stuff like that but the moment you raise prices of even vegetables because they get sick more often because they don't have antibiotics you know that we're what are we going to do with that of the problem it's a great question about what happens when we start taking action on antimicrobial resistance such as to limit the use of antimicrobials what happens then for other things like the cost of food and the so the answer is those are exactly the questions we need to be thinking about as well but I don't think it's as severe as I don't think those consequences are as severe as as maybe you might be worried about for example currently antibiotics when we get an antibiotic we they're quite expensive or they can be quite expensive when we go to a pharmacy and order them farmers on the other hand can buy antibiotics online in big bulk bags by the kilogram we get little tiny pills for us it's available online in industrial grade not for human consumption but it's industrial grade in kilograms and so economists have started to try to address these questions and they think that if we impose tax levy on the sale of antimicrobials just ten dollars per kilogram so for a big bag just put a ten dollar fee on it suddenly in at least North America and then for sure actually the rest of the world most of the lowest value use of antimicrobials and animals would suddenly become no longer cost effective it becomes cheaper to use alternatives in order to achieve the same goals so I mean ten dollars per kilogram is still ten dollars per kilogram but what we need to do is somehow increase the cost whether it's through regulation or through a Pagovian tax which would then allow to discourage this kind of use whether because law prohibits it or because it's not economically viable and one doesn't need to eat organic food so my the code I use I look for antibiotic free some organic food is antibiotic free but a lot of other food is not and for me I focus on land animals which is where there's the greatest human the greatest risk to humans yeah fish is much more complicated there's a right over here I'm curious as to whether having things that have active bacteria such as yogurt would help this situation in terms of plus persistent bacteria or being humans as to not getting bacterial infections to be in one or would it make it worse? I'm I'm not I'm not a physician I wouldn't the question was whether the consumption of live bacteria such as in yogurt would maybe provide some protective effect I mean to the so I'm not a physician I don't I don't know the exact answer but to the extent that we can prevent infection from happening it then reduces the need to actually use these kind of products so I'm I don't know what this I don't know the science of of like probiotic I think is what yeah I don't know the science on probiotic but if it if it works then that would be great that way I'm not the concept of an international tree which is always strong so in theory I like that concept in practice I'm a little cynical about international trees and you might know more about them than me in terms of you or in international order but I've been involved in a couple of trees and we have signed them and whatever they get verified by provinces they learn topics in which their responsibilities for health care for example are totally provincial so how do you get a federal treaty to be verified by the provinces and how do they then the way you deliver how the surface is like government doesn't even deliver them like there's different bodies like physicians are independent they have friends are independent like how is that going to work in a country like Canada like I know that it gives a global profile and it's good thing to do so I'm just going to adhere like in practice like if you kind of thought through all of those complications that we have to go through and the groups that would have to jump through to get that treaty actually working on it yeah so it's a the question of the challenge of implementing international treaties in countries with federal structures so that's a challenge that's a challenge for all treaties for countries with federal structures and it's not just Canada that has a federation the United States has 50 states and many countries use federal models for which it's always a challenge the international legal obligation rests on the national rests on the state as a whole and that state has a legal obligation to work with its provinces or sub jurisdictions to make sure that it's in compliance we have some success we have a lot of success our federal government often talking to our provincial governments on these issues human rights for example in the health world there's the international health regulations which governs how we respond to pandemics when it was revised in 2005 and when the public health agency of Canada was created there's a lot of impotence to get coordinated across the country because what happened during SARS specifically in Toronto in 2003 whereby there was not communication between the Toronto health authorities with the provincial health authorities and then up to the federal government what it meant is that Canada was not able to report the federal government which had the legal obligation was not able to report to WHO the World Health Organization what the state of affairs was in Toronto as a result the World Health Organization slapped a travel advisor against Toronto no information meant they took the precautionary principle so Canada was highly incentivized to change but I don't think what happened today in the same way so that's a collaboration yeah maybe that's that's maybe part of it I know I think I've neglected this side of the room because of the way I'm is there any questions here or there no okay I'm sorry great good luck a question it's kind of a piggybacking the issue of the other side I was wondering if it's possible to kind of implement policies that could prevent prices being so high in terms of having access to a healthier lifestyle so that you won't have to use so many empty my closures so in this type of intervention can you possibly produce those type of policies yeah so the question is whether we can focus more attention on preventing disease in the first place staying healthy to then avoid the need for more antimicrobial use so yeah I think I mean health promotion public health these are areas of our health care system which are grossly underfunded there's been attempts to try to provide more funding to public health for example and health promotion it's really hard when there's patients who have particular diseases and need access to particular drugs which already aren't covered in most provinces and it's really it's politically extremely difficult you have a face of it's really it's the difference between a real life that's there and that can get a photo in the front page of a newspaper versus a statistical life which we don't know when we benefit we've all benefited from public health most people in this room are living are living longer than the average age of people who lived several hundred years ago so we're all most of us are here for public health but we don't think of it like that and we don't invest accordingly so I'm all in favor of doing exactly what you've described the challenge will be is that it's a bit distal in that there is this live problem and if we did that which I hope we do but there's this very pressing problem which we also need to address and I guess there's and there are things we can do about it great over here yeah oh I'm sorry yeah so we can take that one final question and then we're I'm afraid out of our time so do you want to let you choose who gets the final I don't it's mine okay yes okay what are the pharmaceutical companies doing yeah so it's mixed in a sense so at the World Economic Forum last week there was 80 pharmaceutical companies the biggest ones plus others came together the CEOs with a statement saying that they would like to see additional public funding for them to do innovation so surprise I know and we shouldn't be so surprised that industry wants more funding to do innovation but what was also good about it is that they acknowledged that there is a need for alternative market models that they know that with public funding comes some other things like a commitment or for example maybe even not using existing intellectual property regimes so maybe they just help develop it and then anyone around the world can can create it but for a fee I mean they need to be incentivized so they they express great interest in exploring alternative economic models yeah so you're saying pharmaceutical companies have a poor record of social responsibility yeah well they some are better than others but I mean so pharmaceutical companies they're not in favor of everything so for I mean conservation efforts would restrict the size of their markets to sell the existing drugs that they make so they don't like that they don't like bands on advertising front-line is like that and it was quite shocking to them that when they went into pharmaceuticals they said why would we develop a drug that somebody is going to use once we're more interested in long-term yeah that's why we prefer to develop a treatment rather than a cure yeah great so thank you so much please join me in thanking you