GLOBAL HEALTH SECURITY

Intro: Drug-resistant infections now kill more people every year than HIV or malaria, yet only six companies remain active in antibiotic research

Writing in the last few days, Professor Lord Darzi, FRS, said that big pharma is failing to tackle our greatest medical threat.

The world-renowned and eminent surgeon says that every caesarean section, joint replacement, and round of chemotherapy depends on antibiotics. In medicine as in war, a successful attack needs a solid defence. Antibiotics are not medicine’s glamourous front line – they are its foundations. And those foundations are crumbling.

Citing that drug-resistant infections now kill 1.27 million people every year, by 2050 the toll could reach eight million. The current mortality rate is more than HIV or malaria. The World Health Organisation (WHO) has warned that one in six bacterial infections is already resistant to standard treatment.

Yet this growing threat has been neglected by the very industry that has the capacity and resources to confront it. The major pharmaceutical companies walked away from antibiotics when they stopped generating lucrative returns. In the 1980s there were 18 companies involved in antibiotic research. By 2020 the number had fallen to six. The rest have pivoted to focus on expensive but highly remunerative medicines to beat cancer and long-term conditions such as obesity.

The ways in which these new medicines attack disease is indeed transformative, but they do not save lives all by themselves. Patients undergoing treatment are at higher risk of infection, but without effective antibiotics, the surgeon cannot operate safely, the oncologist cannot deliver chemotherapy, and the transplant physician cannot suppress rejection.

It is strategically incoherent to innovate relentlessly in attack while underinvesting in defence. The defensive arsenal is not optional infrastructure. It is foundational.

Between 2011 and 2020, US venture capital invested just $1.6bn in antimicrobials, compared with $26.5bn in oncology. The antimicrobial pipeline has declined by 35 per cent since 2021, from 92 to 60 projects, according to the 2026 AMR Benchmark report by the Access to Medicine Foundation, last month. Half are led by GlaxoSmithKline (GSK), which is carrying a disproportionate share of the large-company burden.

There are now only 3,000 active antimicrobial resistance (AMR) researchers worldwide, against 46,000 in oncology. When antibiotic programmes close, 90 per cent of researchers leave the field entirely. The talent and expertise needed for these medicines is collapsing alongside the drug pipeline.

This weakness puts at risk the pharmaceutical industry’s own growth. In 2024, global oncology revenues exceeded $200bn and R&D investment surpassed $40bn. Yet one-third of cancer patients develop bacterial infections during treatment, and up to half of these are now resistant – causing delays, dose changes, and poorer outcomes.

Developing new antibiotics is especially challenging. Most drugs succeed commercially by reaching as many eligible patients as possible. But for antibiotics, good stewardship means reserving novel agents for resistant infections – precisely the behaviour that collapses commercial returns.

In 2020, a consortium of more than 20 major pharmaceutical companies committed around $1bn to bridge the “valley of death” between discovery and profitability by creating the AMR Action Fund. The fund’s ambition was to deliver two to four new antibiotics by 2030. To date, it has delivered one – pivmecillinam, for urinary tract infections.

Bold initiatives such as this $1bn scheme look impressive. But there is a danger of their becoming “guilt capital” – spending that looks responsible but does not change the underlying economics. Without genuine pull incentives, and without adequate investment in diagnostics, stewardship, and surveillance alongside drugs, the spending risks being perceived as reputational insurance rather than strategic investment.

Most tellingly, the fund itself acknowledges it “struggled to find investment opportunities in clinical development exactly because the pipeline is insufficient”. When a $1bn fund cannot find enough assets worth backing, the problem is not capital. It is upstream failure to generate candidates and downstream failure to create a market that rewards success.

The conclusion is quite simple. We need a new approach.

First, build a sustainable pipeline through modern discovery – including AI-enabled research that must prove itself with real-world data – and implement payment models that reward access rather than volume. The UK’s subscription-style scheme is now being expanded. Similar approaches in other countries could create a viable global market.

Second, reduce misuse through transformative diagnostics. Rapid pathogen identification and resistance profiling at point-of-care would cut inappropriate prescribing – the single largest driver of resistance – and protect new drugs from the fate of their predecessors. A deadline should be called: no antibiotic prescription without a diagnosis by 2030.

Third, strengthen stewardship, surveillance, and access so that new antibiotics are protected, monitored, and reach patients appropriately anywhere in the world – particularly in low-income and middle-income countries where the burden of resistance is heaviest.

In 2028, we will mark the centenary of Alexander Fleming’s discovery of penicillin at St Mary’s Hospital in London – a moment that launched the antibiotic era and transformed human health. The centenary should be a moment of celebration. It risks becoming a memorial if action is not taken.