Slow-motion pandemic: the UN Political Declaration on Antimicrobial Resistance
New York, concrete jungle where Political Declarations are made of
The lights will inspire you... If you’re there. Sadly I was not, but leaders from around the world gathered for the 79th UN General Assembly in New York last month. I watched the talks – new level of nerd unlocked – on catchup on UN Web TV.
One of the high-level meetings this year was on antimicrobial resistance (AMR) and the proposed Political Declaration on AMR later signed by member states. The first, and last, time a high-level UN meeting on AMR was held was back in 2016. In the meantime, research published in The Lancet has predicted that there could be 1.91 million deaths directly attributable to, and 8.22 million deaths associated with, AMR per year by 2050 if action is not taken, so I’d agree it seems a good time for a large-scale discussion and to hammer out some next steps.
(Quick warning for the faint of heart, there are some small swears later on in this newsletter, so watch out for those if you are not a fan of that sort of language.)
Read more about AMR and infection prevention in my last post:
Everything everywhere all at once: a ‘one health’ approach
Key to the Political Declaration (‘PD’ from now on) is the concept of a ‘one health’ approach to AMR. While it is easy to think of AMR as a purely medical issue, human health does not exist in a vacuum. One health approaches are multi-sectoral and aim to improve the health of people, animals, plants and the environment while working across all political levels – local, regional, national, global – to achieve optimal health. This approach recognises that human health is fundamentally connected with animal, planetary and environmental health.
In the case of AMR, for example, antimicrobials used in the agricultural sector pre-empt illness, stop the spread of disease and promote growth in fish, animals and plants. This increases yields and productivity for farmers, keeps creatures and plants healthier and keeps costs down for consumers.
However, this practice also affects animal health, human health and the environment by increasing AMR in a variety of ways: residues of antimicrobials from agriculture can be found in food, impacting human health; runoff from agriculture full of antimicrobials enters the soil, rivers and seas, coming into contact with microbes in different environmental systems and allowing them to develop resistance. Equally, human healthcare can have an impact on the environment and AMR in the form of antimicrobials present in municipal, hospital and pharmaceutical waste and wastewater entering the environment.
This is why the UN leadership on this issue are drawn not only from WHO, but from the World Organisation for Animal Health (WOAH), the Food and Agriculture Organization (FAO), and the UN Environment Programme (UNEP), known together as the ‘quadripartite’, for the purpose of ensuring policy reaches all these areas:
[Signatories] Recognize that antimicrobial resistance is one of the most urgent global health threats and development challenges and demands immediate action to safeguard our ability to treat human, animal, and plant diseases, as well as to enhance food safety, food security and nutrition, foster economic development, equity and a healthy environment, and advance the 2030 Agenda for Sustainable Development Goals.
Political engagement
It is lovely to see these agencies working together on AMR across multiple sectors and regions, of course, but how do we actually make a difference beyond having a good chat about the issue?
Peter Singer, a former Special Advisor to the WHO Director General, writes a series called ‘Get Sh*t Done’ about – as may be obvious – how to get shit done, and also why shit doesn’t get done.
(These are the swears I warned you about and as you can see it is entirely respected public health expert Professor Peter Singer’s fault. You should subscribe to his newsletter).
He argues in this essay that the UN is better at planning than execution, suffering from ‘a failure to execute on what’s already agreed… The UN suffers from planning disease’. He offers three suggestions for how they could better get shit done:
Data, to allow analysis of how execution is going and where barriers to success may be
Innovation
Governance by member states with incentives and accountability
Prof. Singer knows his stuff when it comes to getting big global organisations moving, so how does the PD stand up on these three points?
Data
Between the 2016 meeting on AMR and the follow up last month, important progress was made globally on strengthening AMR ‘surveillance’ (the collection, analysis and interpretation of data). WHO’s Global Antimicrobial Resistance and Use Surveillance System (GLASS) provides a standardised approach to data collection so results can be compared in this compellingly clickable dashboard. I do like a data dashboard.
While the above map shows that good progress has been made in global coverage, the PD acknowledges that there are disparities in the capacities of surveillance systems and gaps in data and data sharing. It makes commitments to strengthening national capacities for surveillance, encouraging all nations to use GLASS (and equivalent systems for agriculture) by 2030, improving access to diagnostics, and requests support from the quadripartite organisations and other UN entities in achieving this.
This is also a focus of related plans (like the IPC one), and seems to be an effective measure of success with the dashboard making it easier to note areas for improvement. The engagement rate is impressive, if we think for a minute about how big and busy the world is, although tempered by the fact that only 68% of countries with action plans are actually implementing them.
Innovation
This is a huge problem in the field of AMR. As I mentioned in my last newsletter, there is a dry pipeline for new antibiotics – there were 20 companies investigating this area in 2000 and only five today, almost no new classes of antimicrobials have been discovered since the 1980s, and there has been a ‘dearth of creativity in the area’.
It is recognised in the PD that:
… lack of investment, poor professional incentives and declining employment opportunities, amongst other factors, are leading to an increasing number of researchers leaving the field of antimicrobial resistance research, resulting in a loss of vital scientific and research talent and a drain on invaluable and much-needed knowledge and expertise.
The commitments of the PD acknowledge the important role to be played by the public, private and academic sectors, promote technology transfer, price transparency and commitments to voluntary licencing to allow equitable access, and focus on training, development, recruitment and retention.
One element which seems to me to be missing from all this is money. A commitment is made to explore innovative financing and raise US$100 million for the AMR Multi-Partner Trust Fund, which is one of those numbers which sounds like a lot but I imagine probably isn’t in the great scheme of things. Once countries have used this to develop and implement surveillance and National Action Plans by 2030, there may not be much left over for the expensive process of research and development (R&D), so the means of innovation remain an issue.
Governance, incentives and accountability
The PD places ‘the primary role and responsibility of governments at all levels to determine their own path towards achieving universal health coverage, including through addressing antimicrobial resistance, in accordance with national contexts, priorities and needs.’ (PD, Point 18). It commits to ensuring all countries have developed or updated and started implementing plans by 2030, and leads by committing to update the overarching WHO Global Action Plan on AMR by 2026 and establish an independent panel for evidence for action against antimicrobial resistance.
Governments will need to be incentivised to provide funding to achieve the recommendations of the PD and encourage R&D. What might motivate politicians? Here in the UK it appears to be free Taylor Swift tickets, but more typically (and not unrelatedly) it is avoiding expensive shocks to the economy, unless you are Liz Truss.
Most politicians are not Liz Truss, so, as the World Bank notes in Drug-Resistant Infections: A Threat to Our Economic Future, ‘economic interest provides an impetus to political action’. In this report, the authors model two scenarios to show the potential impact of AMR on the global economy, which was defined in this case as shocks to labour supply and livestock productivity:
In the optimistic case of low AMR impacts, the simulations found that, by 2050, annual global gross domestic product (GDP) would likely fall by 1.1 percent, relative to a base-case scenario with no AMR effects; the GDP shortfall would exceed $1 trillion annually after 2030. In the high AMR-impact scenario, the world will lose 3.8 percent of its annual GDP by 2050, with an annual shortfall of $3.4 trillion by 2030.
A Threat to Our Economic Future, p. xvii
This is is a greater economic shock than the crash of 2008, and would occur annually and get worse as AMR gets worse, rather than sluggishly recovering, as we slowly and unevenly have been since 2008. The shock will also fall disproportionately on poorer countries.
However, this is also an opportunity. If 8.22 million preventable deaths by 2050 are not incentive enough for governments to address AMR, the World Bank’s prediction should be:
Putting funds into AMR control is likely to be among the highest-yield investments that countries and partners can make today. Assuming that 50 percent of AMR costs can be avoided by robust containment efforts from 2017 to 2050, AMR investments of just $0.2 trillion will bring cumulative global benefits between $10 trillion and $27 trillion during this period. Rates of return on AMR control investments through 2050 may range from 31 percent annually (if only 10 percent of AMR costs can be mitigated) to as much as 88 percent annually (if 75 percent of AMR costs are avoided).
Hammering home that the actions recommended in the PD pose a solution to a serious economic threat may move governments to act, but accountability in this plan ultimately relies on UN attendees and the rest of us working in related fields caring enough to throw energy into following through on recommendations and lobbying for their adoption.
Appealing to our better natures and reminding us that to prevent AMR is a global public good, like Taylor Swift or not ruining the economy, and therefore worth that commitment of time and money is ultimately how we keep pressing forward against this huge challenge of our time.
A call for corrections!
I hope you enjoyed this first Substack. I am not a health professional, I am a writer and publisher working in the field, and I want to communicate these issues to a wider audience. I welcome feedback, corrections, more information! Please feel free to send me a message or leave a comment if you have thoughts or suggestions on making this a better resource for all.
What else
I read, watch, listen… here’s what I’ve enjoyed these past few weeks, I hope you enjoy it too!
Everybody in the Place
Not related to health or policy at all, just something which made me feel old. Please enjoy this documentary in which artist Jeremy Deller attempts to teach beumsed/disinterested A Level students about acid house.
So that’s the end of my second newsletter, sent this time to some people, which was certainly a lot scarier than sending it to no people. Thank you for your support!