Antimicrobial resistance: action must shift towards prevention

The road to the UN

The scale of the problem has led the UN general assembly to convene a high level meeting on AMR during its 79th session in September 2024.3 The aim leading up to the meeting will be to draft, and then agree on, a political declaration on AMR, possibly linked to high level targets that can be used globally. In the run-up to this meeting, many international organisations, including the World Bank,4 have put forward their preferred AMR policy options.567

The World Bank has chosen to emphasise classic, evidence based, and cost effective interventions such as infection prevention and control; improved infrastructure for water and sanitation; strengthened surveillance; increased oversight of antimicrobial use by veterinarians; and increased access to diagnostics and vaccination for human health and agriculture. These commitments take a One Health approach—spanning human health, agriculture and food, water, and the environment—and are largely focused on prevention. The World Bank report states that “investments are aimed at strengthening and developing agricultural, health and water and sanitations systems, which are critical to preventing the emergence and spread of resistance.”4 Such preventive measures are especially vital in low and middle income countries, where the burden of AMR is highest and resources are limited.

The World Bank report differs from the others because, as well as its “top 20” interventions, it acknowledges the broader political landscape of military conflicts, displaced peoples, and climate change. The report states that “taking action on climate change will decrease the likelihood of extreme weather events and the associated spread of resistance,”4 and outlines feasible and responsive strategies, such as building water and sewerage infrastructure to respond to climate risks. However, global leaders will need to go further and tackle the root causes of climate change; otherwise they risk perpetuating the notion that the best we can do is mitigate the climate crisis, whereas it is imperative to champion effective solutions.

The World Bank report also states that indigenous communities “often reside in remote and underprivileged areas” and face “multiple challenges in health care access,” which may hinder effective management of resistant infections. This consideration of the vulnerabilities of indigenous societies, which have historically been affected by colonisation, displacement, and extreme weather events, is welcome. However, there is also potential to learn from indigenous knowledge systems, especially those in which the wellbeing of an individual is inherently connected to the wellbeing of the land.8 These historical, philosophical, and spiritual approaches lend themselves to sustainable models for community and environmental renewal9; in other words, such models are the original One Health strategy.

The past decade of global AMR policy has largely focused on technological or market based solutions, many of which have been underwhelming, failed to materialise, or not delivered equitable gains.10 This World Bank report, along with others,56711 shifts the focus towards prevention and the key tenets of public health, which aligns better with the needs identified by experts working in relevant contexts. For example, Ramanan Laxminarayan of One Health Trust wrote: “We can prevent infection, so that we don’t have to have antibiotics, and we don’t have to worry about AMR in the first place.”12 Infection prevention and control, vaccination, and better water and sanitation infrastructure are incontrovertibly effective and come with numerous benefits beyond AMR. Any AMR mission that focuses on the foundations of global public health, such as those in this report, is likely to gain broad support at the UN general assembly.

The pervasive lack of comprehensive local data on interventions is a key challenge that will hinder the ability to set appropriate targets at the UN general assembly and assess progress towards them. Local data, especially from low and middle income countries, is essential for tailoring prevention efforts and supporting sustainable AMR surveillance. Investing in data to support effective prevention strategies must therefore be a priority.

How can coordination and collaboration be agreed across the UN general assembly to develop measures that will reduce AMR morbidity and mortality globally? By prioritising prevention, supported by comprehensive data and sustainable surveillance, and not shying away from coterminous crises such as climate change, we can and must make meaningful progress against AMR to safeguard global health.