Thank you very much.
Thanks for the opportunity to appear before the committee on this issue and to provide an international perspective.
As a Canadian who grew up on a farm, did a graduate degree in agricultural economics, practised medicine, and has spent the last two decades working in global health on the frontiers of west Africa and south Asia as well as with multilaterals such as the World Health Organization and the World Bank, I will say it is a great privilege and honour to be allowed back into Canada to share some perspectives on this issue.
It goes without saying, but I'm going to say it nonetheless, that antimicrobials represent one of the greatest marvels of modern medicine. In less than a century, billions globally have benefited from antimicrobials, and hundreds of millions of lives have been saved. The benefits, however, have been far from equitably distributed, and far too many people, especially in poorer countries and communities, remain without access to these invaluable life-saving commodities. The magnitude of this shortfall is non-trivial. Many of the deaths of over two million children due to pneumonia and diarrhea every year could be prevented if health systems were able to provide timely access to good-quality, low-cost antimicrobials.
The access deficit we're all concerned about in making sure people have access to life-saving medicines is actually being accelerated by antimicrobial resistance. We just heard about the case of tuberculosis, which is really the cause célèbre in terms of the driver of AMR globally. But in the context of concerns about AMR, the World Bank, with support from the Public Health Agency of Canada and from other governments, undertook a study on the economic costs and impact of AMR, entitled “Drug-Resistant Infections: A Threat to Our Economic Future”, which we published in March 2017.
This report simulated the costs of AMR to the global economy using scenarios, and in the optimistic case of low impact, AMR by 2050 would amount to a reduction of 1.1% of global GDP. By 2030 this would shave about $1 trillion off global GDP annually. In the high-impact scenario, the reduction of global GDP in 2050 would be 3.8% with an annual shortfall of $3.4 trillion in global GDP as of 2030.
To put this in perspective, at their worst, the costs could be as great as the losses incurred during the 2008-09 financial crisis. However, the AMR impact is much worse for two reasons: one, the GDP loss would be expected not once but annually over the 20-year period 2030-50, and, two, it would disproportionately affect lower-income economies.
A critical dimension of the cost relates to international trade, especially with respect to livestock and livestock products, with reductions of as much as 11% projected in low-income countries. Along with that, we would anticipate costs of health care to rise—from taking care of much more complicated patients—by as much as 25% in low-income countries.
If we look at the aggregate impact against the World Bank's primary goal of eliminating extreme poverty, in the high-impact scenario, 28 million people would be impoverished by AMR by 2050, the large majority of whom live in low-income countries.
AMR is not just a health care issue; it is a development issue, which if unaddressed threatens to derail economies and the achievement of our most fundamental development goal at the World Bank, which is to eliminate extreme poverty.
The report not only spelled a picture of doom and gloom in terms of the costs of inaction but also looked at why investing in AMR makes good sense. We used two standard metrics to assess interventions. One is the net present value. We found that between $10 trillion and $26 trillion of benefits could be realized with a $0.2 trillion investment globally over the period 2017-50. When we look at the other investment criterion—expected economic rate of return—that would be somewhere between 31% and 88% depending on how effective the interventions were on an annual investment of $9 billion. It's a very good EER or expected economic rate of return.
If the benefits of action make good health and economic sense, what's the way forward? Recognizing the growing political consensus to tackle AMR, let me just touch on a few areas where the World Bank is actively engaged.
In the area of health, we are actively promoting an agenda of universal health coverage, together with the WHO. There are three reasons why this is good for AMR.
The first reason is universal immunization. If all children in the world had access to pneumococcal conjugate vaccine, not only would this save millions of lives, but this would be an incredibly cost-effective investment to stem antibiotic resistance to pneumococcal infection. The World Bank, as a co-founder of Gavi, the Vaccine Alliance, to which the Government of Canada is a major contributor, introduced an advanced market commitment in 2008 as an incentive to vaccine manufacturers to produce pneumococcal conjugate vaccine in sufficient quantities with a guaranteed price. The impact of the AMC has been to accelerate introduction of PCV in low-income countries. However, we're still well short of 100% coverage.
The second reason is to look at how we finance health systems. Universal health coverage means moving from systems of health financing, where patients pay for care when they're ill, to systems that prepay and pool resources through insurance or tax. There are lots of reasons why this makes sense as an equitable and efficient way of financing health systems, but it also makes good sense for antimicrobial resistance.
In pay-as-you-go financing systems, antimicrobial resistance rates are much higher and in pooling systems, they're much lower when you compare across countries. We're looking at ways in which we can accelerate the move toward prepayment systems for universal health coverage, in particular, working through our global financing facility for “Every Woman Every Child”, which is also an initiative supported by the Government of Canada, which aims to transform financing of health systems in low-income countries.
The third reason is to make sure that we secure essential public health capacity everywhere. The Ebola crisis in west Africa in 2014, like SARS in 2003, alerted the world to the dangers of turning a blind eye to the systems necessary to keep the public's health safe. Chief among these essential capacities are laboratories for disease surveillance. We've found that regional networks of laboratories in Africa provide particularly cost-effective ways of building AMR surveillance.
Two weeks ago, I was in Uganda and saw a reference laboratory for tuberculosis that was receiving sputum samples from as far away as Liberia and Somalia. They were doing highly sophisticated drug-susceptibility testing to monitor TB resistance in these countries. The scale efficiencies in establishing networks of core public health capacities are a designated focus of IDA. IDA is the World Bank Group's fund for the poorest countries, to which the government of Canada is a major contributor.
Beyond health, we're also investing through our agricultural global practice and recognizing the ubiquitous use of antibiotics as growth promoters for livestock and aquaculture. Building on the One Health principles, we've adopted a three-pronged strategy in agriculture: mitigate to reduce use, adapt to reduce the need, and innovate to optimize the use. We're encouraged by recent evidence that restricting the use of antibiotics in food-producing animals is associated with a reduction in AMR. Similarly, we are inspired by the innovative use of vaccines for salmon that has decreased dependence on antimicrobial use in the Norwegian salmon farm industry.
However, given the complex realities of livestock and aquaculture systems in low-income countries, we believe that more basic information and innovation are required. In that regard, we're working very closely with IDRC, the International Development Research Centre, to pioneer an interdisciplinary research agenda that could generate a much better understanding of current patterns and trends on AMR use in livestock production and stimulate innovation towards lower- or no-use antimicrobial systems in low-income countries.
With that, I would like to close and thank the Government of Canada for the opportunity to provide this perspective. I congratulate the committee for considering how to accelerate more concerted action on AMR, both at home and abroad.
Thank you.