In 1941, Albert Alexander, an off-duty Oxford policeman, became the first critically ill patient to receive antibiotic treatment, starting a global trend of antibiotics being used for everything from treating infection to promoting agriculture. Enthusiastic and untampered use has come at a cost, however, and antimicrobial resistance (AMR) now threatens the global community. Bacteria and other microorganisms are evolving to fight back, resisting the antibiotics meant to fight infection and waging a microscopic war with catastrophic consequences.
Dr. Ramanan Laxminarayan, director of the Center for Disease Dynamics, Economics & Policy (CDDEP) and senior research scholar at the Princeton Environmental Institute (PEI) at Princeton University, is one of the war’s leading generals. His 20 years of AMR research have helped bring this issue before the United Nations General Assembly (UNGA) this September. There, he hopes, member countries will move toward a resolution which will lead to a reduction in bacterial resistance and preserve global access to effective antimicrobials.
PEI reached out to Laxminarayan to learn more about this issue, his work, and the potential significance of this first-of-a-kind UN General Assembly on antibiotics.
Much of your AMR research will sit before the UNGA this September. Would you explain AMR and why it is of global concern?
Antimicrobial resistance, or more broadly, the issue of people having access to effective antibiotics, has been of growing concern in recent years. This is a result of bacterial resistance, which means that eventually, antibiotic drugs will evolve to the point of ineffectiveness. As a result, diseases we can easily treat now could become no longer treatable.
This issue requires global collective action because no single country can solve this problem. As resistance is so easily spread, AMR requires all nations to work cooperatively.
How is AMR connected to a broader set of environmental concerns?
This is an issue of global resources, quite similar to climate change in that actions taken by single countries have significant consequences for everyone else. For example, if China emits a lot of carbon, that increases atmospheric carbon across the world. Similarly, if China prescribes too many antibiotics or distributes them freely to livestock, they’ve affected the efficacy of antibiotics for the global population, not just for the Chinese. Essentially, AMR is an ecological and planetary health issue. When you think about it, bacteria are everywhere, impacting our entire ecosystem.
Are usable antibiotics a nonrenewable resource, like fossil fuels?
In a sense, we can think of antibiotics that way. When we look at all the antibiotics we use and were effective 20 years ago, we see that many of them don’t work very well anymore. Although they all work against some bacterial infections, today’s antibiotics certainly lack the broad effectiveness we saw 20 years ago.
Resistance is, in a sense, inevitable. Resistance to antibiotics has been rising ever since they have been used. Antibiotic effectiveness is a natural resource similar to a nonrenewable resource. The difference is we can renew antibiotics, but only if one is able to find new ways of attacking the bacteria. Such renewal requires either curbing use of antibiotics or making large investments in new antibiotics.
To combat AMR, you outlined three propositions for the UNGA meeting. First, you would like the United Nations to establish targets for reducing drug-resistant infections. What does this entail?
It is impossible to achieve any sort of progress without goals or targets and so my colleagues and I propose three goals for pushing back against AMR. The first is to enact mandatory reduction in antibiotic consumption per capita throughout all countries that currently have a per capita consumption above the median. This includes countries such as Spain, Algeria, Turkey, and the United States. Research suggests that this alone could reduce overall consumption by about 17.5%.
Next, there needs to be a reduction in the use of antimicrobial growth promoters in the agricultural sector. This sector represents a massive amount of use which could be eliminated over the next 10 years.
Finally, the UN should track resistance levels at the scale of nations and the world. Existing organizations offer opportunities to provide data to permit national and global AMR surveillance but new investments will also have to be made.
These goals with their associated targets are negotiable, but should be considered carefully, as a resolution that has no targets whatsoever would be ineffective.
After developing these three targets, what are the next steps the United Nations should take to address AMR?
The United Nations must develop adequate financing for global action and define the global health architecture. Funding is absolutely critical because each target requires financing, particularly in developing countries. The United States currently spends $1.2 billion per year on AMR, including innovation, surveillance, and education. Scaling that to other countries based on a constant expenditure per dollar of GDP, we estimate that combating AMR at the global level will require about $5 billion a year.
However, that is small change compared to the current cost of the problem, which in the United States alone is estimated to be about $35 billion a year. Further, we are paying a steep mortality cost; it’s estimated that over 200,000 newborns die from drug-resistant infections every year. Additionally, many surgical patients, especially the elderly, have unfavorable outcomes as a result of drug-resistant infections. Overall, the $5 billion investment is well worth the high return.
What is the significance of this UNGA meeting?
It is relatively rare for a health topic to be featured at the UNGA high-level meeting when the heads of state are present. However, the pressing issue of antimicrobial resistance has been considered worthy of that level of attention and will be addressed for the first time by the UNGA high-level meeting in September this year.
The World Health Assembly, which governs the World Health Organization, first brought AMR to international attention. However, the World Health Assembly found that this issue reached outside their domain of human health; AMR significantly impacts animal and ecological health. Therefore, it demands attention from many UN agencies that are not just concerned with human health and requires much more coordination than is possible by the World Health Organization alone.
However, it was that recognition from the World Health Assembly which pushed the AMR initiative to the UNGA and its high level personnel. Notably, AMR is only the fourth-ever health issue and the first One Health Issue to be discussed at a UNGA high-level meeting.
What do you mean by “One Health?”
One Health issues are ones that relate not just to humans or animals or the environment, but all of these together. AMR is not just a human health issue; it’s also an animal health issue--we use antibiotics to treat sick animals as well as sick people. Animals are affected as livestock, pets, and part of our ecosystem and so untreatable ill animals puts a significant amount of the population at risk.
As a human health crisis, AMR is unusual because it’s not the same as Ebola or other infectious outbreaks. It’s a multi-textual issue that we will see more often and needs to be addressed quickly.
As an AMR expert, what is your role in the upcoming UNGA meeting?
In addition to attending the General Assembly, I am involved in organizing an event on AMR on the sidelines of the United Nations meeting. I’ve also been involved in helping draft the resolution, but at the end of the day, the resolution is only agreed upon by representatives from member countries. So while experts can provide input, the final decision is made by countries. Every country at the UN gets a vote, whether they’re as small as Fiji or as large as China. It’s an interesting process, and I’m hopeful that process will end with a resolution addressing the three key elements in fighting AMR. The best case scenario is as straightforward as setting targets, regulating funding and establishing the global architecture because that then sets the stage for any future development.
What is your professional connection to AMR?
I’m an economist and an epidemiologist by training and have worked on some dimension of AMR for 20 years, closely studying the health consequences at stake for both humans and animals.
My work at PEI and CDDEP examines antibiotic resistance as a global commons issue, a multinational problem not unlike climate change and other ecological issues. While tempting to see AMR as an issue of human health, it’s an ecological problem with human health consequences. The fundamental issue at stake is one of overuse of a global resource. In that sense, AMR is unlike other health issues.
This is an issue I care very deeply about because there is no substitute for antibiotics and we don’t really know how we are going to deal with infectious disease in 50 years. If we use up the antibiotics we have right now, we are faced with two options: either spend a huge amount of money trying to find new antibiotics which may not work as well as the ones we currently have, or face a reality where people get sicker or even die from infections which are easily treatable today. We must, therefore, think carefully about how we use this resource--if we continue to overuse and misuse antibiotics, we will pay a steep price.