A Significant First Step, as UN Member States Declare Antimicrobial Resistance a Global Priority
October 7, 2016
On September 21, 2016, the UN General Assembly convened a High-level Meeting on Antimicrobial Resistance (AMR), only the fourth time in history that the United Nations has organized a high-level meeting on a health issue. Previous meetings were catalyzed by two rapidly emerging epidemics—HIV/AIDS and Ebola—and the growing burden of noncommunicable diseases.
Dr. Margaret Chan, the director-general of the World Health Organization (WHO), likened AMR to a slow-motion tsunami in her opening statement. UN secretary-general Ban Ki-moon posited that AMR poses a long-term threat to human health, sustainable food production, and development, a theme that would be echoed throughout the meeting. The UN High-level Meeting on AMR, and the political declaration adopted at the meeting by all 193 member states, registered a high-level political consensus that AMR is a fundamental global threat that requires the urgent action of all nations across multiple sectors. To be effective over the long term will require committed, coordinated global action. Whether and how that will happen remain unclear.
The full-day meeting commenced and concluded with a plenary chaired by the president of the General Assembly, UN secretary general, and directors-general of WHO, the Food and Agricultural Organization (FAO), and the World Organization for Animal Health (OIE). Between the opening and closing plenaries, representatives of member states gave statements supporting the political declaration and highlighting their countries’ AMR concerns and activities. A concurrent session consisted of two panel discussions populated by ministerial representatives and stakeholders from industry and civil society. The panels focused on the relevance of AMR to the sustainable development goals (SDGs) and the multisectoral nature of the AMR challenge.
Impact of AMR on Low- and Middle-Income Countries and Global Health Security
The impact of AMR on human health and the global economy has been modelled by multiple groups. The UK Review on Antimicrobial Resistance, led by renowned economist Lord Jim O’Neill, indicated that AMR would lead to 10 million additional annual deaths by the year 2050 if left unchecked. The impact on the global economy was also predicted to be significant. If AMR is not addressed, the world economy could lose approximately $8 trillion a year by 2050. Similarly, a new report from the World Bank estimates that by 2050 AMR could reduce GDP by 1–4 percent, an amount comparable to the 2008 global recession. This translates to a loss of $2–6 trillion annually.
AMR affects developed and developing countries alike, but both the O’Neill and World Bank groups report that AMR will disproportionately affect low- and middle-income countries (LMICs). At the UN meeting, ministers and senior officials from LMICs often cited the same concerns about AMR: rising rates of drug-resistant tuberculosis (TB), malaria, and HIV/AIDS; the potential impact of AMR on livestock and food security; and the need for health system capacity building as a requirement for preventing the emergence and spread of drug-resistant infections. These concerns are immediate high-priority issues for LMICs, but the spread of drug-resistant infections will inevitably also affect other countries.
One major example is increasingly drug-resistant TB. Most TB patients can be cured with a months-long regimen of four drugs, but an estimated 5 percent of patients are infected with multidrug-resistant TB (MDR-TB), defined as a TB infection that is resistant to two or more of the most commonly used TB drugs. The majority of patients with MDR-TB develop it after incomplete or inadequate treatment of a bout of drug-sensitive TB. However, MDR-TB bacteria can also be spread through the air from person to person, and an increasing proportion of new patients are contracting MDR-TB directly from another patient. This phenomenon could signal a prelude to faster spread of MDR-TB and the emergence of new outbreaks globally. In the United States in 2015, the number of TB cases rose for the first time in 23 years.
About 10 percent of MDR-TB patients suffer from an even more drug-resistant and difficult-to-treat form of TB called extensively drug-resistant TB (XDR-TB). Secretary General Ban Ki-moon warned that XDR-TB has already been diagnosed in 105 countries. As the Ebola epidemic clearly demonstrated, preventing the emergence and spread of infectious diseases with transborder potential is the most effective approach to ensuring global health security. Treating drug-sensitive TB is an effective way of preventing the development and spread of drug-resistant TB.
To this end, the UN High-level Meeting on AMR may have catalyzed the formation of a new global political will to address drug-sensitive as well as drug-resistant TB. Dr. Aaron Motsoaledi, South Africa’s minister of health and chair of the Stop TB Partnership, alerted the gathering that drug-resistant TB is the leading cause of global AMR deaths, and in 2015 TB became the leading cause of global infectious disease deaths. Minister Motsoaledi issued a call for the United Nations to convene a high-level meeting on TB during the 2017 General Assembly in order to address this important global disease. Separately, the Russian Federation announced its intention to host a global ministerial meeting on TB in 2017.
Drug-resistant malaria also poses a potential risk to global health security. Artemisinin-resistant malaria is currently confined to the Greater Mekong subregion of Southeast Asia (Cambodia, Laos, Myanmar, Thailand, and Vietnam), but it threatens to spread. Artemisinin-based combination therapy is the most effective malaria therapy today, but studies have documented 40 percent of malaria cases in Cambodia as already artemisinin resistant. If artemisinin-resistant malaria spreads beyond Southeast Asia to India and Africa, decades of substantial progress against malaria will be reversed. A wave of chloroquine-resistant malaria previously spread in a very similar route from Asia to Africa, resulting in a global resurgence of malaria. History should not be allowed to repeat itself.
AMR Stakeholder Engagement
There were multiple opportunities for stakeholder involvement during the High-level Meeting and at numerous side events organized by governments, industry, and civil society organizations. One session of the meeting presented two panel discussions that enabled representatives of industry and civil society organizations to tackle thorny AMR issues with heads of state and ministers of health from a few countries. Several themes emerged from the two panel discussions, including the notion that many of the SDGs will not be achievable without solving the problem of AMR. Advances in HIV/AIDS, TB, malaria, and maternal and child health are threatened by AMR. Kenya’s cabinet secretary for health, Dr. Cleopa Mailu, remarked that availability of water and sanitation could be compromised by the release of antibiotic compounds into the environment. Sustainable food production must be achieved without a massive increase in the amount of antibiotics used in livestock and agriculture, an outcome that has been predicted as middle-income countries increase their production of food animals.
Innovative ideas are needed to address the multisectoral challenges of AMR. New incentives and regulations could enable stewardship of antibiotics in the human and animal health sectors. Dr. Jorge Lemus, the minister of health of Argentina, which is one of the largest producers of chicken meat, claimed that regulations on the use of antibiotics in agriculture would need to be set at an international level because of the extensive international trade of meat products. World Bank vice president Keith Hansen proposed an insurance scheme to protect farmers against loss of livestock so that they do not use more antibiotics, presumably for disease prevention.
Interestingly, there did not appear to be significant representation from LMICs among the observers and stakeholders participating in the formal High-level Meeting on AMR. Many global health organizations are relative newcomers to the issue of AMR. Civil society organizations from LMICs may become more engaged as they appreciate the relevance of AMR to their priority concerns. Indeed, a senior official from the South African government remarked that South Africa became more heavily involved in international AMR policy development because of its relevance to the fight against MDR-TB. In recognition of the current and potential threats posed by drug-resistant TB and malaria, the U.S. Centers for Disease Control and Prevention (CDC) hosted a side event at which CDC director Dr. Thomas Frieden, industry leaders, and academics engaged with other stakeholders on the need for concerted efforts to address these two diseases.
At least two new stakeholder alliances were launched at other side events, a sign of strong interest by civil society organizations to remain involved in implementation activities, help establish benchmarks, and monitor progress toward those benchmarks. The Conscience of Antimicrobial Resistance Accountability (CARA) is led by the Center for Disease Dynamics, Economics and Policy (CDDEP) and eight other founding members. The Antimicrobial Resistance Coalition was launched by the Center for Global Health and Diplomacy.
Pharmaceutical Industry Response
At a side event hosted by the United Kingdom, a group of primarily large pharmaceutical companies came together to launch an “Industry Roadmap for Progress on Combating AMR.” The 13 signatory companies agreed to four actions designed to conserve current antibiotics and promote the development of new agents. First, they agreed to improve the management of antibiotic discharge into the environment from their manufacturing processes.
Second, the companies will support antibiotic stewardship in human health through education of health care professionals, eliminating promotional activities that do not align with stewardship goals and working with governments and stakeholders to reduce unregulated antibiotic purchasing (e.g., through nonprescription Internet sales). It will be interesting to monitor the extent to which companies voluntarily eliminate some of their promotional activities, as current business models tie antibiotics revenue to volume of sales.
Third, companies pledge to work with governments and stakeholders to ensure mechanisms of global access, including in LMICs. Finally, signatories will work to create new international clinical trials networks and augment current pre-competitive and public-private collaborations.
The actions in this Industry Roadmap mirror ongoing discussions regarding a global development and stewardship framework called for by the WHO Global Action Plan on AMR and reaffirmed in the UN AMR political declaration. A preliminary report on the framework was presented at the 2016 World Health Assembly and included a range of possible actions to promote appropriate use; develop new drugs, diagnostics, and vaccines; and implement mechanisms of access. The final framework could take the form of a nonlegally-binding recommendation or a legally-binding regulation or convention. Members of the pharmaceutical industry appear to be taking a first step, perhaps to forestall future international regulations.
The UN High-level Meeting on AMR culminated in adoption of a political declaration by all 193 member states, signaling a commitment to work together to combat AMR. Secretary-General Ban Ki-moon exhorted the assembly to turn the commitment into “swift, determined action,” which would need the cooperation of multiple sectors and sustained financing. Through the political declaration, member states agreed on three concrete actions: (1) develop and mobilize resources to implement national action plans on AMR, in line with the WHO Global Action Plan on AMR and using a multisectoral One Health approach; (2) call for WHO to finalize the global development and stewardship framework to support the development and distribution of new antimicrobials, diagnostics, and vaccines; and (3) request the secretary-general to establish an interagency coordination group, cochaired by the Office of the Secretary-General and WHO, to guide and ensure sustained effective global action to address AMR and to report back to the General Assembly in two years on progress, further developments, and additional recommendations.
The UN High-level Meeting did not break new ground in any issue area but brought a high level of political affirmation to actions previously taken by WHO in concert with FAO and OIE. Adoption of the declaration is a significant achievement that may provide some government officials with leverage to seek resources and implement necessary actions, as noted by Argentinian minister of health Lemus. The secretary-general should quickly establish a UN interagency coordination group, as agreed to in the political declaration, and the group should begin its work by establishing clear benchmarks and metrics to monitor progress in implementation of the WHO Global Action Plan on AMR. The process should not be unduly cumbersome but should allow for external stakeholder input. In the current era of tightening resources, honest discussions about prioritized actions and competing priorities must also occur, and countries must find a way to commit sustainable resources to the fight against AMR.
Audrey Jackson is a senior fellow with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.
Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).
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