Antimicrobial resistance calls for the brainpower of a space agency and the militant zeal of an NGO

The cost of infectious disease is somewhere between staggering and incalculable. Approximately $ 8 trillion and 156 million years of life were lost in 2016 alone. Throughout human history, plagues have wiped out more lives than famine and violence.

Then, in 1941, the era of antibiotics began when doctors at Radcliffe Infirmary and Oxford’s Dunn School of Pathology first tested penicillin on a patient. When I was a medical student there in the late 1970s, we felt a certain respect for this achievement that changed the world. Penicillin and its successors have saved millions of lives.

So, 50 years later, as a doctor visiting Gulu Hospital in Uganda, I was heartbroken to see patients die despite being treated with antibiotics. Sara, for example, a young Sudanese refugee, died of puerperal sepsis because she was resistant to first-line antibiotics. And modern and expensive versions were not available.

Antibiotics are part of a group of drugs called antimicrobials – including antivirals, antifungals, and antiparasitics – that prevent and treat infections in humans, animals, and plants. But, as the coronavirus has reminded us, all living organisms mutate. When that leads to resistant ‘superbugs’, we get antimicrobial resistance – the drugs are no longer effective.

Antimicrobial resistance is a consequence of the overuse and abuse of antimicrobials. It is a global problem. But in developing countries, antibiotics are readily available without a prescription. Residents of Kibera, a low-income colony in Kenya, for example, consume more antibiotics than typical American families. However, when a poor patient cannot afford the full course, they settle for a few pills. It can be harmful if an infection is not fully treated, and antimicrobial resistance can result.

Meanwhile, the parallel lack of hygiene, water and sanitation in overcrowded and disadvantaged communities means more disease. This increases the need for antimicrobials.

Antimicrobial resistance also compromises human health through food. Two-thirds of all antibiotics are used in farm animals. Heavy use to fatten animals and hide poor husbandry is a powerful source of resistance. Powerful drugs leached into the soil and water are recycled back to us through the food chain. Antimicrobial residues in milk, eggs, meat and fish are of concern to our health.

Antimicrobial resistance kills an estimated 700,000 people worldwide each year. This could increase to 10 million per year by 2050, at a cost of 100,000 billion dollars. It is one of the top ten threats to global health.

Now is the time to make bold efforts on antimicrobial resistance. This requires a dedicated organization with the universal legitimacy of a UN body, the political weight of a G20, the deep pockets of a global fund, the gray matter of a space agency, the militant zeal of a NGO, the revolutionary power of a social movement and the capacity of a public-private partnership.

Drug resistance and health

Antimicrobial resistance has devastating consequences. For the sick, it means being sicker for longer, wasting money they cannot afford, and impoverishing desperate families. Or succumb to ordinary lung and urinary tract infections that were easily treatable earlier. Traditional threats to public health such as tuberculosis, malaria and HIV are also making a comeback as serious illnesses resist first-line drugs.

Drug resistance is especially bad for critically ill patients with diseases ranging from COVID-19 to chronic bronchitis who are prone to secondary infections. It also becomes more risky to perform organ transplants or administer cancer treatment, as immunocompromised patients need antimicrobial coverage.

A broken market

Drug resistance meets the definition of a pandemic and comparison with other pandemics is instructive. Investing heavily in coronavirus research was worth it as there are billions of permanent customers for COVID-19 vaccines and treatments. In contrast, nothing new has entered the antibiotic cabinet since the 1980s.

It can take 15 years and a billion dollars to develop a new antibiotic. And then, either the poor cannot afford it, or consumption must be limited to avoid future resistance. Meanwhile, companies that have monopoly rights to niche antimicrobials are profiting with abandon.

In contrast, 20 preventable and treatable tropical diseases that weaken 1.7 billion poor people – mostly in Africa and South Asia – are neglected. This is because the remedies are often too cheap for sufficient profit to be derived from them. They include river blindness, guinea worm, leprosy, and elephantiasis.

The unique circumstances of antimicrobial supply and demand mean that inequity prevails, as with COVID-19 vaccines where developing countries are denied the intellectual property rights to manufacture them.

A previous generation struggled similarly during the height of the AIDS epidemic. South Africa and India have led the fight to waive restrictive trade rules on the production of generic drugs, when public health emergencies warrant. It saved thousands of lives as cheap antiretrovirals became available.

A comparable approach is now urgently needed to help all countries obtain effective and affordable antimicrobials. But the outlook is not good, if the current battle to increase COVID-19 vaccine supplies – led again by South Africa and India – is any indicator. Polarized geopolitics is not helpful in mending the shattered essential drugs market.

Health

The painful lesson of pandemics such as Ebola, HIV and COVID-19 is that human, animal and planetary health are intertwined. This is because animals get closer to humans. Their habitats are compromised by development practices that create large-scale deforestation. Thus, their germs jump to us more easily. This situation is exacerbated by environmental changes due to climate change. The trend requires finding new antimicrobials for the diseases to come.

Siled approaches will not work in interconnected contexts. Integrated work is needed to tackle the multidimensional causes and consequences of our disgusting humanity, ecosystem and planet. This “one health” approach could tackle antimicrobial resistance. But the concept remains nebulous. Society and institutions are not encouraged to work across sectoral and disciplinary boundaries.

A technocratic approach is not enough

The World Health Organization has partnered with the World Organization for Animal Health and the Food and Agriculture Organization to sound the alarm on antimicrobial resistance with a plan to global action, several World Health Assembly resolutions and a group of high-level world leaders. Technical tools and guidance are available for national action plans: 89 countries have them but only 18 in Africa and 23 in Asia-Pacific. They include strengthening surveillance, promoting antimicrobial stewardship, training and capacity building.

It’s all worth it. But there is no time to wait. A technocratic approach and scattered funding have not created the necessary momentum.

The first AIDS activists achieved the same in the 1980s, when many countries were devastated, especially in Africa. A massive global movement has been born to change social morays, shake up pessimistic establishments, galvanize massive funding for research, prevention and treatment. And it sparked extraordinary innovations in the biological and behavioral sciences.

His legacy goes far beyond HIV. It also led to the creation of UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria as specialized institutions to energize and orchestrate an unprecedented global enterprise.

The hugely disruptive COVID-19 crisis sparked comparable efforts with breakthroughs in technology in record time, a reversal of economic orthodoxy, and unprecedented funding. Innovations in our way of working, of designing social safety nets, of reconfiguring international cooperation, of generating solidarity and of empowering political decision-makers. But we also deepened the inequalities and realized that globalization itself needs a makeover.

There are excellent examples of what could constitute a global organization dedicated to the fight against antimicrobial resistance. Connecting them is the necessary organizational innovation. It means challenging small institutional battles and sectoral boundaries, and overcoming small states of mind.

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