Antimicrobial resistance (AMR) is one of the greatest challenges of the 21st century.
Tackling the problem calls for engaging the health, agricultural, trade and environment sectors; here is a look at the various aspects of it.
What is AMR and how serious it is?
Antimicrobial resistance is the phenomenon by which bacteria and fungi evolve and become resistant (drug resistance) to presently available medical treatment.
AMR is said to be a slow tsunami that threatens to undo a century of medical progress.
It is already responsible for up to 7,00,000 deaths a year.
Unless urgent measures are taken to address this threat, the world could soon face an unprecedented health and economic crisis.
It could lead to 10 million annual deaths and cost up to $100 trillion by 2050.
How does drug resistance develop?
Drug resistance in microbes emerges for several reasons including -
the misuse of antimicrobials in medicine
inappropriate use in agriculture
contamination around pharmaceutical manufacturing sites where untreated waste releases large amounts of active antimicrobials into the environment
All of these drive the evolution of resistance in microbes.
This is compounded by the serious challenge that no new classes of antibiotics have made it to the market in the last three decades.
This is due to inadequate incentives for their development and production.
A recent study found that over 95% of antibiotics in development today are from small companies.
And 75% of this have no products currently in the market.
Major pharmaceutical companies have largely abandoned innovation in this space.
What are the implications?
AMR represents an existential threat to modern medicine.
It could lead to a condition without functional antimicrobials to treat bacterial and fungal infections.
So, even the most common surgical procedures, as well as cancer chemotherapy, will become fraught with risk from untreatable infections.
Neonatal and maternal mortality will increase.
All these effects will be felt globally, but the scenario in the low- and middle-income countries (LMICs) of Asia and Africa is even more serious.
LMICs have significantly driven down mortality using cheap and easily available antimicrobials.
In the absence of new therapies, health systems in these countries are at severe risk of being overrun by untreatable infectious diseases.
What does this call for?
Tackling these diverse challenges requires action in a range of area.
In addition to developing new antimicrobials, infection-control measures can reduce antibiotic use.
A mix of incentives and sanctions would encourage appropriate clinical use.
At the same time, it is critical to ensure that all those who need an antimicrobial have access to it.
5.7 million people worldwide die annually because they cannot access drugs for infections that are treatable.
Further, to track the spread of resistance in microbes, surveillance measures to identify these organisms need to expand beyond hospitals.
It should encompass livestock, wastewater and farm run-offs.
Also, microbes will inevitably continue to evolve and become resistant even to new antimicrobials.
So, there is a need for sustained investments and global coordination to detect and combat new resistant strains on an ongoing basis.
There is the critical role of manufacturing and environmental contamination in spreading AMR through pharmaceutical waste.
So, there is a need to look into laws such as those recently proposed by India, one of the largest manufacturers of pharmaceuticals.
The law aims to curb the amount of active antibiotics released in pharmaceutical waste.
What is the need for caution?
Various countries are taking measures at individual an coordinated level.
The range of initiatives that seek to control the emergence and spread of AMR is welcome.
But, there is a need to recognise the limitations of a siloed approach.
Current initiatives largely target individual issues related to AMR (such as the absence of new antibiotics, inappropriate prescription and environmental contamination).
Thus they focus narrowly defined groups of stakeholders (providers, patients and pharmaceutical companies).
Regulating clinician prescription of antimicrobials alone would do little in settings where -
patient demand is high
antimicrobials are freely available over-the-counter in practice, as is the case in many LMICs
What should the approach be?
Efforts to control prescription through provider incentives should be accompanied by efforts to educate consumers.
This will help -
reduce inappropriate demand
issue standard treatment guidelines that would empower providers to stand up to such demands
provide point-of-care diagnostics to aid clinical decision-making
Policy alignment is also needed much beyond the health system.
Solutions in clinical medicine must be integrated with improved surveillance of AMR in agriculture, animal health and the environment.
In all, successful policies in individual countries are no guarantee of global success.
International alignment and coordination are paramount in both policymaking and its implementation.
Indeed, recent papers have proposed using the Paris Agreement as a blueprint for developing a similar global approach to tackling AMR.
