Executive summary

Superbugs, the colloquial name for strains of bacteria which have become resistant to antibiotics, present one of the most significant global health threats of the 21st century. Every year, nearly 1 million people worldwide die from drugresistant infections. With that figure projected to climb to 10 million by mid-century, medical experts now put drug resistance in the same bracket as the HIV/AIDS crisis, and are calling for a coordinated response from the international community to address the threat.

It has taken years of sustained effort to place drug resistance on the international agenda, but at long last the medical experts’ pleas are beginning to reach the ears of politicians. At the G20 in Hangzhou in September 2016, world leaders acknowledged the serious danger to public health, growth and global economic stability posed by antimicrobial resistance (AMR), a sentiment echoed at a special United Nations High-Level Meeting dedicated to the topic later on that month. However, despite this heightened sense of urgency, concrete action on tackling drug resistance remains slow and incomplete, and many seasoned observers fear that we are doing too little, too late.

Against this sombre backdrop, the evidence is piling up that global pharmaceutical companies – whose role it should be to cure sick people and channel resources into the development of new medicines – are actually contributing to the spread of drug-resistant infections through pollution at their own production sites or those of their suppliers. A series of recent reports have shone a light on this, the third major cause of AMR, by revealing how dirty production processes and the dumping of inadequately treated antibiotic manufacturing waste in China and India, where the lion’s share of our drugs are made, is fuelling the worldwide spread of superbugs, amplifying the already considerable impact of the excessive consumption of antibiotics in human medicine and their profligate use in livestock rearing.

This report, for the first time, exposes the occurrence of resistant bacteria surrounding pharmaceutical manufacturing plants in India and maps out the supply chain which delivers antibiotics from the dirty factories where they are produced to patients in Europe and the United States. An on-the-ground investigation by the investigative agency Ecostorm which took place in June 2016 and subsequent analysis of water samples under the supervision of Dr Mark Holmes from the University of Cambridge found high levels of drug resistant bacteria at sites in three Indian cities: Hyderabad, New Delhi and Chennai.

In total, out of 34 sites tested, 16 were found to be harbouring bacteria resistant to antibiotics. At four of the sites, resistance to three major classes of antibiotics, namely the cephalosporins, carbapenems and the fluoroquinolones, was detected. At eight of the sites, resistance to cephalosporins and fluoroquinolones was detected. At a further four of the sites, resistance to either cephalosporins or fluoroquinolones was found. Of the antibiotics manufacturing plants tested, three factories respectively belonging to Aurobindo Pharma, Orchid Chemicals, and Asiatic Drugs and Pharmaceuticals, all of which supply export markets either directly or indirectly, were found to be resistance hotspots.

Detailed examination of publicly available supply chain data, and evidence obtained through Freedom of Information requests, has uncovered how antibiotics manufactured by these companies are being exported to the European and U.S. markets, including the United Kingdom’s National Health Service (NHS), French hospitals, and German healthcare companies and U.S. pharma giants. Further supply chain links were also uncovered between polluting Chinese factories and Western markets.

Although probably just the tip of the iceberg, this analysis adds to the current body of knowledge on the impacts of pollution in pharmaceutical supply chains and shows that urgent action is needed to address this problem. In the current era of international travel and trade, once created, superbugs can spread quickly around the world, meaning that pollution from drug factories in India and China is not just a localised problem for people living in these areas, but could accelerate one of the biggest global health crises facing humanity this millennium.

One company in particular, Hyderabad-based Aurobindo, emerges as one of the worst offenders. A recidivist polluter at its own production sites in India, it also imports the raw materials used for making antibiotics from dirty factories in China. With strong commercial links to major players in the pharmaceutical industry, including U.S. giants McKesson and CVS Health, and an international network of subsidiaries affording direct access to Western export markets, Aurobindo has ambitions to continue expanding its global presence and market share. But at what cost to human health?

This report sends a clear message that when it comes to addressing AMR, we must address each and every one of its three causes: human, animal and industrial, or else risk losing the fight completely. With growing awareness of the gravity of the threat posed by effluent from antibiotics plants, major purchasers of antibiotics, whether publicly-owned bodies or private companies, must use their buying power to make the pharmaceutical industry clean up its act. The failure to bring manufacturing waste under control is unacceptable, presents a clear public health threat, and negatively impacts the industry’s reputation as a whole. As such, this is an issue that should be of concern to pharmaceutical companies’ customers, investors, and public health authorities alike.

With pharmaceutical supply chains still shrouded in mystery, purchasers should demand much more transparency on the origin of our antibiotics, requiring moves from the pharmaceutical sector mirroring those undertaken by the textiles industry in the wake of tragedies such as the Rana Plaza disaster in Bangladesh. A series of practical steps for the industry and regulators are presented at the end of this report, setting out a blueprint for best practice in a sector whose environmental performance leaves much to be desired.