Executive summary

The effective treatment of infections and diseases, which has been taken for granted for decades, is under threat. The emergence of virulent strains of drug-resistant bacteria, commonly known as superbugs, is prompting scientists and medical practitioners around the world to warn of a return to the pre-antibiotic era and a looming public health disaster.

Antimicrobial resistance (AMR) has been singled out as one of the main risks to mankind by the World Health Organization (WHO) and governments everywhere. The Chairman of a major UK Government-backed review into AMR estimates that by 2050, drug-resistant infections could kill 10 million people per year globally, and the UK’s Chief Medical Officer has spoken of a “catastrophic threat.” AMR is also extremely costly, with studies showing that the world could lose up to US$100 trillion worth of economic output between now and mid-century if it is not addressed, lowering projected GDP by 2 to 3.5 percent.

The global spread of AMR means that serious and highly contagious illnesses such as gonorrhoea and pneumonia, may soon become incurable. As the number of untreatable cases rises worldwide, doctors and medical staff are increasingly falling back on antibiotics of last resort.

There are several factors fuelling the AMR crisis. An inexpensive and seemingly endless supply of antibiotics, coupled with perverse financial incentives encouraging their prescription, are leading to inappropriate use and overconsumption in humans and animals reared for food. The lack of investment by industry in new drug discovery is further exacerbating the situation.

One frequently overlooked cause of AMR, and the focus of this report, is environmental pollution from the production of the raw materials used to make antibiotics at the very beginning of the supply chain.

Most of the world’s antibiotic drugs are manufactured in China and India. China is now the top manufacturer of penicillin industrial salts, a vital building block in the production of many antibiotics, and produces 80-90 percent of antibiotic active pharmaceutical ingredients (APIs). India, which has the world’s third largest pharmaceutical industry, represents a smaller yet still sizeable share of global antibiotic API manufacturing. Indian companies have also positioned themselves as leaders in the production of ‘finished dose’ antibiotic products using APIs mainly imported from China. The trade in antibiotic drugs between China and India is now worth billions of dollars, with large pharmaceutical companies in the United States and Europe among their biggest clients. In 2014, China was rocked by a series of investigations exposing pollution from antibiotics factories.

The pharmaceutical industry has long maintained that antibiotic manufacturing does not play a significant role in fuelling drug resistance, arguing that the final product is so valuable that it would not be economically rational to discharge vast quantities of it as waste. However, the Chinese revelations as well as several scientific studies have clearly demonstrated that this is not the case.

Hot on the heels of the recent pollution scandals, this report documents links between some of the global pharmaceutical industry’s biggest household names and dirty antibiotics factories in China. On-the-ground investigations and desk research have uncovered a complex and murky web of commercial relationships between Chinese suppliers, Indian middlemen, and trusted global brands. While information on where pharmaceutical companies source their antibiotics may be provided confidentially to national authorities, it is classified as commercially sensitive, making it impossible to fill the supply chain gaps highlighted in our research.

Despite the shocking lack of transparency in the global pharmaceutical supply chain, our investigation has revealed that Pfizer is among the well-known brand names which has sourced antibiotics for human and animal use from NCPC, a company that stands accused of discharging pharmaceutical effluent into the environment and numerous other serious manufacturing deficiencies. There also appear to be direct links between one of the world’s largest generic drug manufacturers, McKesson, which owns several European brands, and Indian company Aurobindo, which sources from at least four polluting Chinese factories. The world’s largest generics manufacturer, Israeli company Teva, likewise has links with at least three of the Chinese companies identified in this report, all of which have been in the Chinese media spotlight for various offences including improper waste management and the release of noxious chemicals.

The report reveals that the largest pharmaceutical corporations are complicit in fuelling one of the most serious public health crises facing society today. It is essential for pharmaceutical companies to lift the veil on their supply chains and stop buying antibiotic APIs from polluting Chinese factories. In an age when AMR is threatening to destroy the health system as we know it, there is simply no excuse for turning a blind eye.

Policy-makers should demand more transparency and expand existing production standards and the Good Manufacturing Practices (GMP) framework to incorporate and enforce environmental protection criteria. This is a critical, yet still missing, part of the puzzle in the global strategy to combat AMR.