In this series we ask some of the leading experts in the field of AMR and One Health for their take on progress, leadership and challenges.
Our third interviewee is Anthony D. So, MD, MPA. Anthony is Professor of the Practice and Director of the Innovation+Design Enabling Access (IDEA) Initiative at the Johns Hopkins Bloomberg School of Public Health. He also serves as Director of ReAct’s Strategic Policy Program.
Hi Anthony, what have you been doing on AMR in the last few years?
Till the pandemic struck, much of the past few years were spent advancing global efforts to respond to the challenge of antimicrobial resistance. As the World Health Assembly took up the Global Action Plan on Antimicrobial Resistance in 2014 we co-founded the Antibiotic Resistance Coalition, now comprised of thirty organizations - including the Alliance to Save Our Antibiotics - working across sectors to take up this call, and we continue to serve as the Secretariat for this civil society effort.
As part of ReAct—Action on Antibiotic Resistance, we partnered with the UN Secretary-General’s Every Woman Every Child Initiative to brief delegations in lead up to the UN General Assembly’s adoption of the Political Declaration of the High-Level Meeting on Antimicrobial Resistance in 2016. Much of our efforts had centered around the development of recommendations for the UN Interagency Coordination Group on Antimicrobial Resistance, for which I served as one of the Co-Conveners.
Our research work has spanned the spectrum of One Health concerns, from the 3Rs of innovating novel antibiotics and incentives delinked from volume-based sales to ensuring access but not excess of antibiotic use and understanding the externality of antimicrobial use in livestock.
We also have worked to train future AMR champions through Innovate4AMR (recognized by the UN Innovation Network in 2019), now expanded and brought on-line as Innovate4Health, a global student design sprint to support innovative approaches to tackle emerging infectious diseases.
How has the global AMR community responded to the COVID-19 pandemic?
Much has been written over the obvious: that empiric treatment with antibiotics for COVID-19 patients risks greater drug resistance. Had countries mobilized earlier to address AMR and started to build that public health infrastructure, perhaps COVID-19’s tragic impact might have been lessened.
A few voices, like those in the Antibiotic Resistance Coalition, have pointed out these shared opportunities for response. From zoonotic disease transmission and surveillance to infection prevention and control and surge capacity to deliver needed diagnostics, antimicrobials and vaccines, these building blocks would have served healthcare delivery systems well.
Just a year prior, we had delivered the recommendations of the Inter-Agency Coordination Group (IACG) to the UN Secretary-General. A few of us had warned that “If we hope to have a future free from the fear of untreatable infections, we can now pay to address antimicrobial resistance—or pay much more later.” As the World Bank had projected, it would take just a few billions to stave off trillions of dollars in potential costs from drug-resistant infections by 2030. The Bank described action to address AMR as “one of the highest-yield development investments available to countries today.”
AMR has come more like a rising tide, whereas COVID-19 has descended upon the world like a tsunami: the economic toll of an emerging infectious disease that might have unfolded over a decade has now become telescoped into the space of a year.
What lessons have you learned from this pandemic?
The more important question may be what have our government policymakers learned from this pandemic. Those policymakers who failed to act and call for the billions of dollars needed to address the challenge of emerging infectious diseases, including AMR, can now see the cost of their inaction.
The road into this pandemic has laid bare the deeply rooted inequities in our society. But how can the road out of this pandemic be paved towards greater equity? We have spent trillions of dollars responding to COVID-19, particularly in the United States. This investment was needed but, sadly, this outlay may rob us of the resources - and future investment capital - to build towards a longer-term response to AMR, other emerging diseases, and existential threats like climate change.
We will have to redouble our efforts to make the case for addressing AMR. This may require piggybacking on the infrastructure investments being made for COVID-19--from rapid point-of-care diagnostics and infection prevention and control to pooled procurement and vaccine delivery.
Where can we make the greatest difference in curbing unnecessary antibiotic use in farming and the environment?
By changing how restaurant and grocery chains source their food animal products, consumer and environmental groups are making inroads where governments have failed to act. However, there remains so much to do in ensuring a more sustainable, agroecological approach to how we bring our food from farm to fork.
Many countries have insufficient numbers of veterinarians, so we need to find systemic approaches to improving animal husbandry practices that reach small-scale farming operations and that address not just lives, but livelihoods.
We must pilot approaches to raise livestock that reduce reliance on antibiotics and develop insurance programs that lower the risk to farmers seeking to adopt these new practices.
There are also clear opportunities to target. For example: salmon aquaculture in Chile uses antibiotics, on average, 1500 times more per ton of salmon than in Norway. The Chilean salmon farming industry has struggled with treating its fish against a bacterial disease, salmonid rickettsial septicemia (SRS), and much of the antibiotics used to treat this disease enters the environment. Existing vaccines have proven ineffective. Yet if we applied science as we do in human medicine - in public-private partnerships - to develop an effective vaccine against SRS, we might well make the widespread use of antibiotics as part of routine salmon aquaculture in Chile unnecessary.
What do you think the most important thing is for the next year in fighting AMR?
We have to move beyond policymakers just tiresomely repeating their commitment to a One Health approach to addressing AMR and actually hold our intergovernmental agencies and country governments accountable. Just as surely as form follows function, so financing must match these pronouncements.
We need to establish clear priorities and targets, both at global and local levels, against which we can begin to benchmark measurable change. Along these lines, we have proposed that this might lead to a global AMR Watch, around which civil society groups can mobilize. COVID-19 has provided us an opportunity to test this approach as in our program’s widely reported work on reservations of COVID-19 vaccines for global access demonstrates. In charting a course out of this pandemic, we hope that together we can also piggyback a more effective response to AMR as well.
Thank you for your time Anthony, and for giving us an insight into your work.