AMR: More Than A Global Health Challenge

Daniela Corno
My name is Daniela Corno, and I work for the Global Strategy Lab. Almost a century has passed since the discovery of life saving antimicrobials, making surgeries, chemotherapy and other advanced treatments possible. But there is a problem these medicines are becoming less and less effective.

Daniela Corno
AMR is one of the world’s largest health and development challenges with resistant, harder to treat, infections causing death and debilitation of millions of people every year, especially in low- and middle- income countries. This increase in drug resistant infections and the associated social and economic implications also turned back years of progress on key UN Sustainable Development Goals for health, food, safety and security, economic growth and poverty alleviation. In September 2023, a prominent lineup of global health experts gathered at the United Nations General Assembly Sustainable Development Goals summit to address critical issues surrounding global health equity. But the Sustainable Development Goals won’t be achieved on time if we don’t do more to mitigate the impact of rising AMR on our health systems, food systems and the environment. But before we dive too much into the topic, I wanted to dig into what antimicrobial resistance really means, and what are some ways researchers are currently working to address it. This led me to a conversation with our lab’s very own Dr. Susan Rogers Van Katwyk, an expert on all things AMR.

Susan Rogers Van Katwyk
My name is Susan Rogers Van Katwyk. I’m the Managing Director of the AMR Policy Accelerator at the Global Strategy Lab. And I’m also an Adjunct Professor of Global Health at York University.

Daniela Corno
Even though we’re just at the start of our episode, I feel like a lot of jargon and terminology has already been introduced. Let’s take it back to the basics. In the spirit of Unpacking AMR, I challenged Dr. Rogers Van Katwyk, to explain AMR in simple terms as she would for someone who is completely new to the topic.

Susan Rogers Van Katwyk
So in science, we like to talk about antimicrobial resistance. But in the real world, I think it’s more helpful to think about drug-resistant infections, because that’s usually the challenge that we’re facing when we’re talking about AMR. And we have all of these really wonderful life-saving drugs that we use antibiotics, which are specifically designed to kill bacteria, and the antivirals that kill viral infections, and antifungals that kill fungal infections. And all of these are incredibly wonderful life saving drugs. But the organisms that they are targeted against, are also living organisms and they can develop all sorts of mechanisms to avoid these drugs and avoid the effectiveness of these drugs. And so that’s how we end up with drug-resistant infections, we get these infections that have learned over time, how to avoid drugs. And that means that when we go to treat infections with the tools that we usually use, antibiotics often, they don’t work anymore, and that bacteria doesn’t respond to the treatment. And then we have a real challenge because now we have a bacterial infection. It’s making someone sick. And it’s really, really hard to figure out how we’re going to save that person’s life.

Daniela Corno
So we’re all familiar with this scenario, you’re really sick, you visit your doctor, and they determine you have a bacterial infection and your body needs additional help to fight it off. They prescribe an antibiotic somewhere along the instructions, they underline the importance of finishing your treatment to prevent the development of antibiotic resistant bacteria. However, the problem only gets more complex when we realize that there are more classes of antimicrobials than just antibiotics. To expand on this topic for us, I talked to Dr. Mathieu Poirier, the Co-Director of our lab.

Mathieu Poirier
Hi everyone. I’m Mathieu Poirier. I’m the Co-Director of the Global Strategy lab and Assistant Professor with the School of Global Health at York University and York Research Chair in Global Health Equity.
Yeah, it’s interesting, we often talk about antimicrobials as mostly being about antibiotics. But there’s other things like antifungals, antivirals, and even antiparasitics that are affected by this issue.
So for example, when I was living in the Caribbean, there was actually some active transmission of malaria, including P. falciparum, which is one of the more dangerous types. And it was actually one of the few places in the world where it could be treated by Chloroquine. But around the world this is really no longer used as a medicine and now we rely on artemisinin combination therapy, which is a combination of different drugs that has been shown to be effective in places where resistance to Chloroquine has developed, and it’s a combination to try to prevent resistance from arising in the first place. So this is an issue across multiple different types of pathogens.

Daniela Corno
These explanations and examples are a great way to understand how AMR works and how it affects us. One thing that stood out to me is how focused these descriptions were on treating humans in a healthcare setting. But antimicrobial resistance isn’t just a human health issue. In order to successfully manage AMR, we need to use a One Health approach, which recognizes the impact of antimicrobials on animal health and the health of the environment, in addition to human health.

Susan Rogers Van Katwyk
I think a lot of people are aware of how much antibiotics kind of changed the course of modern medicine. I don’t know if people are quite as aware of how much antibiotics reshaped more of the world around us, because we didn’t just get access to these life saving drugs and say, “Oh, good, this is a medical tool. And we’ll keep it that way.” We also looked around for other places, that it would be helpful to use antibiotics. And so they became almost like this infrastructure part of our society. And so now what we see is that you get a lot of antibiotics that are used in agriculture, particularly antibiotics that are used to treat sick animals. But oftentimes antibiotics that are used to prevent animals from getting sick in the first place when you have lots of animals in crowded conditions. And you want to preemptively ensure that there aren’t going to be any infectious disease outbreaks among you know, your cattle, your chickens, whatever you happen to be raising,

Daniela Corno
Antibiotic use in livestock is a big issue. I know I was surprised the first time I learned that about two thirds of antibiotics use worldwide are for animal production. This widespread reliance on antibiotics brings us to the concept of antibiotics as infrastructure. This is something we tend to overlook when looking at the problem of AMR.

Susan Rogers Van Katwyk
So we have all of these antibiotics that get used in agriculture, where you’re in places that are rural or remote, that have limited resources, limited access to things like clean water, and you still need to deliver a health care system, you often see a lot of antibiotics get used to prevent infections, because you can’t ensure that everything is going to be clean and sanitary the way that you would like to be in a hospital setting. So again, you use a lot of antibiotics to prevent disease, because you want to make sure that people are safe in a healthcare setting.
The challenge is that we have all of these antibiotics that get used in all of these invisible ways. And the more antibiotics that we use, the bigger the risk is that we’re going to create more antibiotic resistance, we make the problem bigger by trying to use the antibiotics in a way that is kind of supporting all of humanity and livestock and agriculture and everything else. So that’s a really big challenge because antibiotics are getting less effective, they’re less effective when we use them in a health care setting, they’re less effective when we use them in an agriculture setting. And then that sometimes means we have to use more of them, or we have to use stronger ones.
And we’re in this terrible circle where the problem gets worse. And we’re trying to solve it. And we go around in loops. And unfortunately, we’re kind of getting to this point where we may in fact go back to not having effective antibiotics where we don’t have those tools, the same way that we originally didn’t have those tools. And that introduces the possibility that there’s going to be more human deaths, more animal deaths, more long term disability or long term hospital stays, and that some of our most essential structures, like health care structures, and food systems might not be able to hold up if we take away the sort of essential infrastructure that underpins everything.

Daniela Corno
One of the big takeaways I got from this part of my conversation with Dr. Rogers Van Katwyk was just how large and complex the issue is expanding way beyond human antibiotic use. Gone are the days where I thought antimicrobial resistance just came from individuals requesting antibiotics when they have a cold, or taking only five days instead of seven of the full prescription. Instead of looking at AMR as a problem created by people asking for too many antibiotics, we need to consider how global governance can be improved.
Now, I hope you’re all still with me, because I have some more concepts to introduce. We are an academic research podcast after all. So who would we be without our terminology? Because antimicrobials will become less effective the more we use them AMR is often described as a common pool resource. Something you may be familiar with if you studied economic theory. In our lab, we’ve been referring to this as a problem with “managing the global antimicrobial commons”. But what exactly does this concept mean?

Susan Rogers Van Katwyk
It’s an interesting concept, where essentially what we mean is that we only have this one pool of effective antibiotics. And everybody is pulling on that pool of effective antibiotics for all of the different healthcare and agriculture needs that I was just talking about. And so the challenge really becomes managing this pool of effective antibiotics. If people try and take too much of that, it’s going to cause problems for others. And so it is this common resource, this common pool, that we have to try to figure out how we manage in an equitable kind of way for everyone all over the world.

Daniela Corno
Figuring out how to manage this common pool in an equitable way is definitely a global issue that requires a global perspective. After getting so much information on the problem at hand, I thought it would be exciting to then look into ways researchers are working to address these issues. The best person for this was obviously our Co-Director, Dr. Poirier.

Mathieu Poirier
GSL is lab, the Global Strategy Lab, and we started about 10 years ago. And our mission has always been to conduct research for better policies and a healthier world. So we do that by advising governments and public health organizations on how to design laws, policies, institutions to make the world a healthier place for everyone. And I’d say that’s something that we put in the centre of all of our efforts is trying to be highly interdisciplinary. Now by that I mean that we bring together scientific expertise from many different fields, fields like law, ethics, public health, economics, political science…

Daniela Corno
Let’s pause here so we can take a closer look at the field Dr. Poirier is talking about. At the Global Strategy Lab, these can be broken into three programs of focus. First, we’ll dive into the Global Legal Epidemiology program. This looks at how international laws affect health worldwide. It’s an emerging field that aims to produce rigorous and impactful research on the international laws, policies and norms that shape our collective health equity and wellbeing. Next, we have Public Health Institutions. This program bridges disciplinary divides to understand today’s public health institutions and advise governments and organizations around the world on institutional design for tomorrow’s challenges. Lastly, but definitely not least, there’s Global Antimicrobial Resistance. This program focuses on the rapid rise of antimicrobial resistance. We work to integrate the science of global strategy on coordinated global action to improve innovation, collaboration and attention among global health actors and the public.

Mathieu Poirier
And one of the key accomplishments that we’ve had over the years was actually in 2019, when we were recognized as a World Health Organization Collaborating Center on the global governance of AMR. So through that role, we directly advise the WHO on providing technical guidance, policy analysis, legal advice on global governance of AMR. And I’m going to actually hand it back over to both of you to cover another big development that’s happened a bit more recently, which is the AMR Policy Accelerator.

Susan Rogers Van Katwyk
Yes. So the AMR Policy Accelerator was really developed as a way to try and mobilize all of the research evidence that we were generating through all of the work we do as the Global Strategy Lab. And to try to find a way to bridge that divide that often comes up between research and policy. So we wanted to make sure that the research we were doing all of the possible solutions for AMR that we were coming up with, actually made it into the hands of people who can act on those kinds of recommendations who craft policy on AMR, for their governments or for their organizations. And so we developed the AMR Policy Accelerator as a mechanism to both do that applied research and then also to advise governments on the AMR challenges that they’re facing in real time where they need policy solution. And our goal really, is to try and bring research evidence into that policy discussion in a way that accelerates global action against antimicrobial resistance. And I mean really helps us achieve our long term goal of having a healthier, safer and more equitable future for everybody.

Daniela Corno
Combining policy research with advisory services and capacity building is a unique way to approach this, but this is no easy task to accomplish by ourselves. Partnerships play a huge role in successfully being able to mitigate the problem of AMR. This common goal has paved the way for the Global Strategy Lab and other research centers to collaborate to develop global governance strategies to tackle AMR. Thus the SAFE AMR Governance Partnership was born.

Mathieu Poirier
So this was really a huge opportunity that we were given by Social Sciences and Humanities Research Council of Canada, often shortened down to SSHRC, where we put forward a proposal to bring together an international network for AMR social scientists. This was, again international bringing together 13 research centres over three continents, and I’d say really importantly, focused on social science because we know that we’re not going to solve AMR, by coming up with the perfect drug or by coming up with like an artificial intelligence prescribing algorithm that solves all these issues. These are social issues. And we need to address the underlying social drivers of AMR if we’re going to solve these issues. If we take a step back and think of AMR as a global issue, that means that we not don’t just have to think about things in one country at a time. But we have to think about all the complicating factors that come up when we think about countries cooperating and oftentimes transferring resources, making compromises and coming up with an agreement to reliably sustainably manage the antimicrobial commons. So our project put forward an acronym, we love acronyms in this field. We call it SAFE Governance of AMR. And that stands for Sustainable, Acceptable, Fair and Effective.

Daniela Corno
And speaking of innovative approaches, I love telling people about how we approach AMR research at GSL. It really highlights what this podcast is all about, the issue being more than just bugs and drugs. I feel like often when I talk to people who are in healthcare research, but in different fields, and I say I work at a lab that researches antimicrobial resistance, but from a social science perspective, it usually makes people’s heads turn and you have to explain it more. It’s exciting, and I’m excited to share more of it all with you, I thought the best way to end this would be to give you all a little sneak peek into what to expect in the near future from both the AMR Policy Accelerator and the SAFE Governance Partnership.

Susan Rogers Van Katwyk
We have a lot on the go at the AMR Policy Accelerator this year. As many people will know, it’s actually a really pivotal year for AMR. Because the United Nations General Assembly is going to have a high level meeting on antimicrobial resistance later this year. And I am expecting that that will be a really pivotal moment where we make a lot of plans for the future, we sort of set the agenda for what the next 10 years of action on antimicrobial resistance looks like. And those high level meetings are a really important moment to engage world leaders in really thinking about what this problem means for them and for their countries.
Our job at the AMR Policy Accelerator is to try and inform all of that action. So we’re working on figuring out how to support governments in making effective AMR policies we can deliver on any commitments that get made later this year. And one of the things that we’re really trying to do is to build out our Advisory Services program. So we’re working directly with countries to feed them the evidence that they need in real time, we’re hoping that countries will come to us with a really concrete questions about how to solve AMR challenges. And then we can find the evidence and the policy analysis that they need to make their plans for the future.
And then in the same vein, we’re also introducing a micro-credit course this year on AMR policymaking. And we’re really targeting that course at technical professionals. So physicians, veterinarians, epidemiologists, microbiologist, people who already know a lot about the science of antimicrobial resistance, and who often end up being put into policy leadership positions within their governments. We want to design this course in a way that will help them understand more of the policy and the social issues that are part of AMR, so that they can combine that with all of the technical skills that they have, and leverage all of those different things to make really strong national and local AMR policies.

Mathieu Poirier
Yeah, and a lot of things that we’re looking forward to with this partnership as well. One of the immediate projects we’re working on is trying to develop what we’re calling a unifying global target for AMR. And with this, we’re, again, we have an eye out to the political dimensions. How do we motivate countries politicians general publics to to support actions needed to address AMR with a really simple and easily understandable global target, similar to 1.5 degrees Celsius of global warming in the world of climate change.
We also are even more fundamentally trying to map out who are the key actors that are working in the global AMR space, as well as trying to identify necessary political conditions for global AMR goals to be considered acceptable around the world. We’ll be conducting a systematic review on existing government policies in antimicrobial use. And we’re always keeping in mind this is a One Health issue involving human animal environmental sectors, looking at agricultural practices that are involving inappropriate antimicrobial use that might be amenable to global regulation. And that’s just a sample of what we’re working on over the next six years or so in this partnership. So a lot to look forward to.

Daniela Corno
Definitely a lot to look forward to. Antimicrobial resistance is one of the greatest threats humanity faces today. The impact of AMR is far reaching with consequences for human health, the global economy, the environment and global health equity, but through collaboration and One Health approach, we can work towards achieving sustainable antimicrobial use for all. Once again, that was Dr. Susan Rogers Van Katwyk, Managing Director of the AMR Policy Accelerator, and Dr. Matthew Poirier, Co-Director of the Global Strategy Lab. Thank you for listening today. If you enjoyed this episode, and haven’t done so yet, don’t forget to like and subscribe to make sure you’re the first to know when we post a new one. Tune in next time as we Unpack AMR.