Antimicrobial resistance is part of a perfect storm of health crises

Abstract

Often events designed to raise the profile of particular health issues or diseases are accompanied by statements measuring progress over the past year or so. For World Antimicrobial Awareness Week (WAAW), Nov 18–24, the message is somewhat simpler: know that antimicrobial resistance (AMR) exists and treat antimicrobials as the precious resource that they are. In a WHO video announcing WAAW, WHO Director-General Tedros Adhanom Ghebreyesus rightly states that AMR is “one of the greatest health threats humanity faces today” and that antimicrobials “are the backbone of modern medicine”. And yet the AMR crisis has been seen approaching for decades, but the reaction has not been commensurate with the risk posed by large-scale resistance. In addition to the ongoing struggle to reduce the unnecessary use of antimicrobials, there is the well publicised problem of the very limited pipeline of new antimicrobials, which we discussed in our May Editorial following publication of the WHO antimicrobial pipeline report. That report acknowledged the scarcity of new drugs in development and the lack of funding needed to encourage innovation. One proposed solution to this funding gap is to provide upfront investment to developers. Although a relatively new idea in terms of funding antimicrobial development, it has been in circulation for some time and is still struggling to gain purchase. An alternative proposal was made in a Personal View by Rebecca Glover and colleagues in the November issue of The Lancet Microbe. Glover and colleagues propose to get around the ongoing problems of commercial innovation by establishment of a global public infrastructure of institutes that will initiate the process of antimicrobial development and see it through to market authorisation. The gist of their proposal is to inject some coordination into the response to the AMR crisis. The solution to the lack of these drugs has not emerged from market-driven approaches, so an exploration of the potential of public bodies to drive development is long overdue. Furthermore, compared with other antimicrobials, market-driven solutions are even less likely to yield drugs to treat neglected diseases predominantly found in poorer nations. In a Comment by Jacob Goldberg and colleagues, published in The Lancet Microbe on Nov 16, we are reminded that any AMR response must be truly global if it is to make genuine inroads into addressing the crisis. Global inequalities in access to antimicrobials is a great source of harm, but inequalities in funding and implementation of plans to respond to AMR are compounding these harms. Goldberg and colleagues point out that low-income and middle-income countries (LMICs) exist at the intersection of multiple health crises, creating clear potential for accelerating and magnifying the AMR crisis. Further complicating the AMR response is the lack of data from LMICs, owing, in part, to the complex settings in which antimicrobial use and resistance rates would need to be measured. An issue that cuts across many facets of health care in nations at all income levels, like the AMR crisis, is not easily solved. It is not a criticism of efforts made so far to suggest that it is time to consider ideas that are not rooted in conventional approaches. However, proposing the central involvement of public bodies in the development of antimicrobials is hardly the radical approach that some stalwart supporters of market-driven solutions might imply. We are already past the point where all suggestions, even those considered radical, should be on the table. Addressing the AMR crisis, much like pandemic preparedness and tackling climate change, needs a long-term view that breaks out of political cycles. Unfortunately, there is limited impetus for policy makers to drive change, because of a belief that solutions can stem from tweaking existing structures and because the sheer scale of the problem makes it difficult to fully appreciate. This final point can be addressed by an increase in the availability of AMR data from around the world and in the most challenging settings. This data gathering will need to be enthusiastically funded if policy makers are to truly understand the scale of what is approaching. It is normal for antimicrobial-resistant organisms to be characterised as the foe in this scenario, but the real enemy is apathy. Unfortunately, apathy is traditionally only overcome when it is too late. The challenges of combatting antimicrobial resistance in the PhilippinesThe Lancet Microbe1 highlighted antimicrobial resistance as a critical yet often overlooked threat to public health. Global inequalities in access to antimicrobials, paucity of data from low-income and middle-income countries (LMICs),2 where antimicrobial resistance is a looming crisis, and perfunctory, if not absent, antibiotic stewardship in most resource-limited tertiary care centres require an urgent response from the international community. In the Philippines, a lower–middle income country in southeast Asia, cultural misconceptions and inadequate regulation and enforcement of antibiotic use have shaped provider and patient attitudes and behaviour. Full-Text PDF Open Access