The number of drug-resistant infections is increasing. So why aren’t we getting new antibiotics?

Nearly a century after Alexander Fleming’s groundbreaking discovery of penicillin, his scientific successors rushed to save modern medicine.

Infections that were once easily cured with antibiotics are now untreatable. A new treatment for bacterial infections is the holy grail for research teams around the world.

But severe financial challenges have left the pipeline of new antibiotics thin and fragile—and treatments unavailable in many of the places where they’re needed most. Big pharmaceutical companies have left the field in search of bigger profits elsewhere, and talented researchers have opted for new jobs in more stable industries.

The number of deaths from drug-resistant bacteria in 2019 was 1.27 millionand the economic costs are on their way to exceed $1 trillion (£765 billion) by 2030The mortality rate is highest in sub-Saharan Africa, where children under five are particularly affected.

“This is a problem that really affects the whole world, rich countries and poor countries alike,” said Jeremy Knox, head of infectious disease policy at Wellcome. “(But) the impact is absolutely asymmetric. People in low- and middle-income countries are bearing a much greater burden.”

World leaders will gather in New York this month to discuss antimicrobial resistance (AMR) at the UN General Assembly. They will consider how to convince researchers and companies that it is worth creating new replacement drugs, and how to improve access to tests and treatments.

The World Health Organization produces a annual list of drug-resistant pathogens of greatest concern. In June Warnings were issued that there were too few antibacterial agents in development to combat them.

“We are facing an innovation crisis,” says Damiano de Felice, chief external affairs officer at Carb-X, a nonprofit that aims to accelerate the development of such products. Since 1990, only one new class of antibiotics has been discovered or patented, he says—a sharp decline when you consider that more than 25 were discovered between 1940 and 1979.

There are many new, promising approaches in the early stages of development, he says, “but most product developers in this space are very vulnerable.”

Of the 112 commercial institutions identified According to WHO, 97 hospitals were conducting preclinical research to develop new products against AMR, but had fewer than 50 employees.

Anand Anandjumar is co-founder and CEO of Bugworks, one of the small companies doing AMR research. “We’re barely 30 people,” he says, adding that the company — based in Bengaluru, India — “couldn’t be here” without the support of funders including the Wellcome Trust, Carb-X and the Indian government.

The few companies that have managed to bring new products to market in recent years have done “very badly” financially, De Felice says, and many have gone bankrupt.

That record scares off commercial investors and contributes to a brain drain Researchers who start in AMR move to other fields after companies go bankrupt or funding is lost.

“It’s very hard to make a lot of money from an antibiotic,” says Laura Piddock, scientific director of the Global Partnership for Antibiotic Research and Development (GardP), who is working on new treatments.

Cheap drugs for chronic conditions like diabetes or high blood pressure can still make companies a lot of money because they are taken by many people for a long time – often a lifetime. Antibiotics, on the other hand, are used for a short period of time to fight infections.

Piddock is optimistic that the scientific challenges of finding new chemical compounds to combat troublesome bacteria can be overcome, especially with the advent of new tools such as artificial intelligence.

The bigger challenge is translating that research into new treatments, she says. “Whether you’re a big pharma or a small nonprofit like GardP, it still costs millions.”

Even access to existing drugs remains a problem in countries of all income levels, she says, with many companies marketing their drugs in fewer than 10 countries “for financial reasons.” It means patients in hospital with sepsis may not have access to antibiotics “that you and I take for granted.”

A Access to Medicine Foundation Report This year, it was found that this was unlikely to change. Researchers looked at five major pharmaceutical drugs in late-stage development for some of the “most serious drug-resistant pathogens,” and identified concrete commitments to register them for use in just five low- and middle-income countries.

According to De Felice, incentives are needed to stimulate innovation, such as subsidies from governments and the third sector to support early-stage research.

There is also a need for incentives that ensure that drugs get to market and that guarantee companies a return on their investment even if the antibiotics are not used but are withheld as a last resort for particularly serious infections.

Some such programs already exist. In the United Kingdom, pharmaceutical companies can receive a fixed annual fee for new antibiotics, regardless of how often they are used. The subscription model bases payments on how valuable the drugs are to the health system.

A similar approach is being considered in the US, although some global health campaigners fear It is too domestically focused and will drive up the prices of new antibiotics around the world, making it harder than ever for people in developing countries to get antibiotics.

According to Piddock, several countries will have to introduce similar incentives to sufficiently stimulate the market.

In countries where it is more difficult to obtain medicines, vaccines are sometimes lacking and even basic water and sanitation facilities are lacking, which increases the risk of infection.

“What we need is to ensure that when we develop new innovations, such as diagnostics and antibiotics, they are accessible and affordable in all countries and for all population groups within countries,” says Esmita Charani, associate professor at the University of Cape Town and honorary lecturer in infectious diseases, AMR and global health at the University of Liverpool.

• Carb-X is part-funded by the Bill & Melinda Gates Foundation, which supports the Guardian’s global development journalism through debewaker.orgRead more about how the Guardian ensures its editorial independence here