Resistance to change? Re-framing policy in the global fight against AMR


Written by Naomi Bull

June 5, 2019

A challenge without borders

A drug-resistant superbug can travel from one side of the globe to another in the time taken for an unwitting passenger to take an international flight. For this reason, antimicrobial resistance (AMR) presents a challenge without borders, threatening all citizens globally.

Drug-resistant diseases currently claim an estimated 700,000 lives each year. Many of us will be familiar with this growing threat and the risks it poses. If resistance continues to rise, routine hospital procedures will become more dangerous and common diseases could be rendered untreatable.

Fair access

However, fewer of us may be aware that more than five million people die annually from infections that are not resistant and would be perfectly treatable with access to appropriate antimicrobials. Many of these are people in low- and middle-income countries (LMICs) where antimicrobials may be unavailable or unaffordable for large proportions of the population. A major new United Nations report on AMR highlights this inequality. It calls for equitable and affordable access to effective antimicrobials to be made an essential part of Universal Health Coverage.

But how do we balance the need to make antimicrobials available to those who require them, with the need to reduce use and improve stewardship practices? One thing is certain, achieving these twin goals will require collective global action.

The language of policy

In order to effect policies which achieve this action, high-level political attention must be attracted to the cause. Highlighting the issues likely to be of greatest political importance and focusing on these is an effective strategy. A recently-published study from authors at the London School of Hygiene & Tropical Medicine (one of LIDC’s member institutions) compares framing of AMR across policy documents. They investigate the way AMR has been represented to governments and the issues promoted as most important.

The analysis reveals that the documents are positioning LMICs as reservoirs and ‘hot spots’ of AMR. There is a narrative of higher-income countries needing to protect themselves from imported cases of AMR, through surveillance of LMICs. This portrayal of AMR as a threat to economic growth and health security in high-income countries has successfully drawn much-needed political attention, and garnered strong political consensus on the issue. So, is it now time for a change in the narrative to support the full participation of LMICs?

Challenges for LMICs

LMICs face specific challenges in the battle against AMR. These include large numbers of informal healthcare providers and often weaker capacity to enforce regulations. We must pay more attention to the language we use when discussing AMR. This should allow for selection of policy options or solutions which resonate more broadly in LMICs.

Examples of more LMIC-oriented policy changes include improving health systems, food security and access to water and sanitation. These options don’t directly act to reduce use of antimicrobials or impose further regulation on their supply. However, they do address some of the key underlying drivers of use in LMICs and would provide many additional benefits to people living in these countries.

The World Health Organisation (WHO) acknowledges that AMR is still not seen as a major development issue. It wants to mobilise resources in LMICs through incorporating AMR into existing programmes. This can’t be seen as a transient project, but needs sustained investment over decades. Case studies have highlighted entry points for AMR activities and the role of development partners within country. Importantly, the WHO has taken a One Health approach, appreciating the interdependency of human, animal and environmental health.

Collective action for global success

Moving forwards, we cannot focus on resistance in isolation and we must not attribute blame if we are to achieve progress in fighting this challenge. Taking a holistic approach to policy design, which considers the different requirements of all countries, is of vital importance. If LMICs are left behind or do not contribute fully to the solutions, the consequences will be global. We still have a long way to go to secure a future with global sustainable access to effective antimicrobials, but evaluating our current approaches and being open to change where necessary is a big step in the right direction. 

Naomi Bull is a Research Fellow at the Royal Veterinary College. A qualified veterinary surgeon, her research interests focus on the application of One Health principles to development challenges. She is currently working on a project investigating risk factors driving antimicrobial resistance in subsistence farming communities in the Global South.