Considering antimicrobial resistance a threat to the world’s sustainable development

Despite many proposals and initiatives in recent decades, the world is failing to keep pace with microbes becoming increasingly resistant to available treatments. Antimicrobial resistance (AMR) is an unavoidable phenomenon that undermines the effectiveness of basic and modern medicine and is affecting people from birth to death everywhere in the world.

The COVID-19 pandemic has shown the devastating impact of hard-to-treat infections, and the ease with which infections can spread and threaten global health security. The threat of AMR to global health security is just as serious. Alarming levels of resistance have been reported in countries of all income levels, with the result that common diseases are becoming untreatable and life-saving medical procedures riskier to perform.

More than 1.2 million people – and potentially millions more – died in 2019 as a direct result of antibiotic-resistant bacterial infections, according to the most comprehensive estimate to date of the global impact of AMR. The analysis of 204 countries and territories, recently published in The Lancet, reveals that AMR is now a leading cause of death worldwide, higher than HIV/AIDS or malaria. Disease burden was estimated in two ways: deaths caused directly by AMR (i.e. deaths that would not have occurred had the infections been drug-susceptible and therefore more treatable), and deaths associated with AMR (i.e. where a drug-resistant infection was implicated in deaths, but resistance itself may or may not have been the direct cause). Deaths caused by and associated with AMR were calculated for 204 countries and territories and reported for 21 global regions and seven super-regions. The analysis shows AMR was directly responsible for an estimated 1.27 million deaths worldwide, and associated with an estimated 4.95 million deaths, in 2019. HIV/AIDS and malaria have been estimated to have caused 860,000 and 640,000 deaths, respectively, in 2019. Deaths caused directly by AMR were estimated to be highest in Sub-Saharan Africa and South Asia, at 24 deaths per 100,000 population and 22 deaths per 100,000 population, respectively. AMR was associated with 99 deaths per 100,000 in Sub- Saharan Africa and 77 deaths per 100,000 in South Asia. In high-income countries, AMR led directly to 13 deaths per 100,000 and was associated with 56 deaths per 100,000. Of the 23 pathogens studied, drug resistance in six alone (E. coli, S. aureus, K. pneumoniae, S. pneumoniae, A. baumannii, and P. aeruginosa) led directly to 929,000 deaths and was associated with 3.57 million. One pathogen-drug combination – methicillin-resistant S. Aureus – directly caused more than 100,000 deaths in 2019, while six more each caused between 50,000 and 100,000 deaths. Across all pathogens, resistance to two classes of antibiotics often considered the first line of defense against severe infections – fluoroquinolones and beta-lactam antibiotics – accounted for more than an estimated 70% of deaths caused by AMR.

To address the challenge of AMR, the World Health Organization (WHO) approved In 2015 at the 68th World Health Assembly in Geneva, the Global Action Plan on Antimicrobial Resistance. Later that year, AMR was recognized as a threat to the world’s sustainability and development efforts in the resolution entitled ‘Transforming our world: the 2030 Agenda for Sustainable Development, which incorporates the United Nations’ sustainable development goals (SDG). Although omitted from specific SDG targets, AMR is included in paragraph 26 which states: “…We will equally accelerate the pace of progress made in fighting malaria, HIV/AIDS, tuberculosis, hepatitis, Ebola and other communicable diseases and epidemics, including by addressing growing antimicrobial resistance and the problem of unattended diseases affecting developing countries..’” Moreover, addressing AMR is integral to achieving SDG. Progress in many of the goals (e.g. ensuring healthy lives and promoting well-being for all at all ages, ending poverty in all its forms everywhere, improving access to clean water and sanitation end ensuring sustainable consumption and production patterns) will help to address AMR. However, at the same time, rising levels of AMR will make it more difficult to achieve the goals for health, poverty reduction, food security, and economic growth. There is increasing recognition of the relationships between human health, animal health, plant production, food safety, and environmental sectors, in both the evolution of the AMR problem and solutions to that problem. To adequately address AMR, it is, therefore, necessary to take a “One Health” approach, with integrated actions across all sectors. Given the scale of the burden of AMR and the many areas of society affected by its consequences, solutions to this challenge should follow an integrated and comprehensive policy approach. AMR must be redefined in a broader context beyond human health, including agricultural and environmental issues, as well as health security, all within the framework of sustainable development.

To avoid an AMR tragedy, antimicrobial effectiveness needs to be recognized as a fundamentally important global public good and governed accordingly. In addition to the Global Action Plan on AMR, there is a critical need for cross-sectoral global action by countries and other stakeholders to complement it. There have been multiple calls from various bodies including the G7 Health Ministers. From May 19 to May 20, 2022, the health ministers of the Group of Seven (G7) met in Berlin, Germany, which concluded with the signing of the G7 Health Ministers’ Declaration. their communiqué covered a range of topics but focused on four priority areas: (1) Overcoming COVID-19, (2) Future pandemic preparedness, (3) AMR, and (4) Health risks from climate change. In a communique issued after their meeting in Berlin, the health ministers of the G7 countries (Canada, France, Germany, Italy, Japan, the United Kingdom, and the United States) called AMR an “urgent public health and socio-economic problem” that may affect the entire globe but have a significant impact on low- and middle-income countries. Acknowledging AMR as a shared responsibility, they committed to “taking further urgent and tangible action” to address the issue. Among the actions, they committed to are establishing new and/or improving existing national integrated surveillance systems on AMR and antibiotic use in the human, animal, plant production, and environmental sectors; promoting prudent and appropriate use of antimicrobials and encouraging antimicrobial stewardship; strengthening implementation of Infection Prevention and Control Programs across the One Health spectrum; and strengthening the research and development pipeline for new antibiotics. The communique also addressed the economic challenges that have stymied the development of new antibiotics and the need for G7 countries to develop incentives to bolster investment in the antibiotic pipeline. “We acknowledge that it is essential to ensure a sustainable market for existing as well as new antibiotics,” the group wrote. “This includes appropriate steps to address antibiotic market failure and to ensure the commercialization and provision of existing and new antibiotics for unmet public health needs while taking into account stewardship and equitable access.” They added, “Recognising country-specific circumstances and member state competencies, we will explore a range of market incentive options, with a particular emphasis on supporting relevant pull incentives.”

The opportunity to track AMR as a threat to the world’s sustainable development coincides with global attention on the priority of ensuring universal health coverage. Effective antimicrobials are an essential building block to delivering universal healthcare. AMR is not a disease for which we should expect ultimately to develop a cure. Instead, it is a silent pandemic that is here to stay. AMR is a phenomenon where microorganisms adapt through evolution to survive the onslaught of antimicrobial drugs. It undermines the treatment of many common diseases as well as standard surgical procedures. As shown above, it is also a challenge to global development at large. Antimicrobial effectiveness must be looked upon as a limited global public good on the verge of becoming scarce, and the world has a collective responsibility to preserve it in order to avoid countless future victims of drug-resistant infections.