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Antimicrobial Resistance; a Global Health Concern Requiring Global Governance

Article by: Enis Bar谋艧, MD, Ph.D.
Professor of Practice
School of Population and Global Health, 捆绑SM社区

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Antimicrobial resistance (AMR) has long been a concern dating back to the discovery of penicillin by Alexander Fleming who at his Nobel Prize acceptance speech in 1945 warned the medical community that 鈥渘egligent use of penicillin鈥� - by which he referred to under-dosage - could lead to resistance. The ensuing golden decades of discovery of new antimicrobials from 1950s to the end of 20^th century - the so-called Antibiotic Era - did not eliminate the microbial threats, mainly because of misuse and overuse of antimicrobials in healthcare and livestock industry, poor sanitary conditions, inappropriate food handling and poor infection prevention and control in hospitals. And now we find ourselves in such a precarious situation facing a global tsunami of AMR that even in his prescience A. Fleming could not have predicted. With very few antibiotics in the pipeline, outdated antimicrobial research and development models and marketing practices, a constant tug of war between the Global North increasingly wary of inappropriate use of Antimicrobials, and the Global South concerned of affordable access thereto, the consequences are staggering; according to a recent report on the global burden of bacterial AMR that in 2019 there were 4.95 million deaths associated with bacterial AMR, including 1.27 million deaths directly attributable to it.

It is not all doom and gloom, however. While the global recognition of, and response to, AMR has been rather tepid for many decades, and louder in words than in action, there has been significant progress since the issuance of the WHO Resolution of the AMR Global Action Plan (GAP) in 2015. It had five objectives:

1. improved awareness and understanding of antimicrobial resistance;
2. strengthened knowledge and evidence base through surveillance and research;
3. infection prevention through effective sanitation and hygiene;
4. optimal use of antimicrobial medicines in human and animal health; and
5. development of an economic case for sustainable investment that takes account of the needs of all countries and to increase investment in new medicines, diagnostic tools, vaccines and other interventions.

The GAP was followed by the High-Level Meeting report at the UN General Assembly in 2016 which kickstarted a flurry of activities, reports and initiatives for global advocacy, governance and action to prevent and contain AMR, and mitigate its consequences on health, healthcare, environment, animal health, poverty and the economy. These included, among others:

1. The UN resolution in September 2016 that led to the establishment of the Inter-Agency Coordination Group (IACG) which in its report in 2019 recommended, inter alia, development and implementation of One Health Action Plans, phasing out of use of Antimicrobials in livestock for growth promotion, increased investment in new antimicrobials, and more effective global governance.
2. AMR featuring prominently in declarations, communiques, and press releases by G7 and G20 since the very first G7 declaration on AMR in Berlin in 2015.
3. The establishment of , , , , ,
4. Several technical reports by the World Bank, OECD, WHO and others on AMR and its impact on health, healthcare and the economy; and more recently
5. Country specific initiatives such as the Infection Management Control Report in the UK.

Yet what seems to be missing is an effective global governance mechanism to lead, steer, advocate for and account for progress on the ground. The existing Tripartite mechanism that brings together WHO, OIE and UNEP, while a great step forward towards the adoption and implementation of One Health, appears to be inadequate given the multiplicity of partners and stakeholders both in the public and private sphere across a range of technological challenges along the continuum, stemming from bench research on novel antimicrobials all the way to trade and economy, and future growth. The economic consequences of AMR have reached too critical a threshold to ignore. Expected losses from AMR between 2015 and 2050 may reach up to $85 trillion in GDP and $23 trillion in global trade, equivalent of up to 4% decline in global GDP by 2050, mostly among the poor in low- and middle-income countries, as a result of decline in livestock production and trade, and increase in healthcare costs. And these estimates were made before the COVID-19 pandemic with its own consequences on inappropriate use of antimicrobials, the surge in demand on public and veterinary health systems and healthcare, and the global economy.

We are at a critical juncture. We must find effective means of governance and accountability to act globally as well as locally to proactively contain AMR and mitigate its consequences through policy, oversight, metrics, surveillance and R&D. The recent evaluation of the progress with GAP made it very clear that the progress thus far has been patchy, with very few success stories in between, and the need for more effective global AMR governance.

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Selected bibliography:

• Institute of Medicine 1992: Emerging Infections: Microbial Threats to Health in the United States. Washington, DC.
• Institute of Medicine 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press.
• Institute of Medicine 2010. Antibiotic Resistance: Implications for Global Health and Novel Intervention Strategies: Workshop Summary. Washington, DC: The National Academies Press. .
• National Research Council 2014. Technological Challenges in Antibiotic Discovery and Development: A Workshop Summary. Washington, DC: The National Academies Press.
• G 7 Health Ministers Release: Berlin Declaration on Antimicrobial Resistance (2015)
• WHO: Global action plan on antimicrobial resistance, Geneva, Switzerland, 2016.
• Political Declaration of the High-Level Meeting of the General Assembly on Antimicrobial Resistance: draft resolution submitted by the President of the General Assembly, 2016.
• National Academies of Sciences, Engineering, and Medicine 2017. Combating Antimicrobial Resistance: A One Health Approach to a Global Threat: Proceedings of a Workshop. Washington, DC: The National Academies Press.
• World Bank 2017: Drug Resistant Infections: A Threat to Our Economic Future, Washington, DC.
• Ahmed SA, Bar谋艧 E., Go DS, et al: Assessing the global poverty effects of antimicrobial resistance. World Development,
• OECD (2018): Stemming the Superbug Tide; Just A Few Dollars More.
• Inter-agency Coordination Group on Antimicrobial Resistance: No Time to Wait: Securing the Future from Drug-Resistant Infections. Report to the Secretary General of the United Nations. April 2019.
• Knight, G.M., Glover, R.E., McQuaid, C.F., Olaru, I.D., Gallandat, K., Leclerc, Q.J., Fuller, N.M., Willcocks, S.J., Hasan, R,, van Kleef, E. and Chandler, C.I.R, 2021. 鈥淎ntimicrobial resistance and COVID-19: Intersections and implications鈥�. Epidemiology and Global Health. eLife. 16 February 2021.
• WHO Evaluation Office: Comprehensive Review of the WHO Global Action Plan on Antimicrobial Resistance, September 2021, Geneva, Switzerland.
• Antimicrobial Resistance collaborators: Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. January 20, 2022.
• National Academies of Sciences, Engineering, and Medicine 2022. Combating Antimicrobial Resistance and Protecting the Miracle of Modern Medicine. Washington, DC: The National Academies Press. .
• ReAct (2022): Systemwide response to antibiotic resistance requires effective and sustainable global governance.
• Infection Management Coalition White Paper (2022)
• Global Research on Antimicrobial Resistance (GRAM) Findings Launch
• AMR Industry Alliance progress Report 2021 (February 2022):
• Global Coalition on Aging: 2021 AMR Preparedness Index. Infection Disease Society of America.