New Conceptions to Manage AMR – Part 1 

Daniela Corno: 
Antimicrobial resistance, also known as AMR, has historically been framed as a problem requiring changes in patient and medical professional behaviour. But the impact of AMR doesn’t stop on humans alone. AMR also increases economic and food security risk. These far-reaching impacts on people, animals, food systems and the environment, means a One Health approach is vital to effectively address AMR.  

Despite warnings from the scientific community to do more to address this problem, One Health whole of society, approaches to this transnational challenge remain scarce. It is because of this that new perspectives are needed to reframe AMR and generate new avenues for policy impact.  

My name is Daniela Corno and welcome to another episode of Unpacking AMR.

On January 19 and 20 the Global Strategy Lab brought together leading social scientists and AMR policy experts at the Wellcome Trust in London. Their goal, to push AMR discussions beyond the usual biomedical lens and explore fresh social science perspectives on the issue. Over two days of dynamic discussions, activities and team building, the group examined AMR through four conceptions: socio-ecological dynamics, antimicrobials as infrastructure, a series of collective action problems and urban political ecology.  

Each of these new conceptions offer a fresh, unique way of understanding how AMR shapes and coexists with our world. In this special edition of Unpacking AMR, we’ll break down each of these concepts across four episodes, and today we’re kicking this series off with the socioecological dynamics of AMR. The term socio-ecological dynamics is a bit of a mouthful. Luckily, Dr. Isaac Weldon and Dr. Ilaria Natali are here to unpack what that means. 

Ilaria Natali: 
My name is Ilaria Natali, and I’m a post-doctoral research fellow at Toulouse School of Economics in France. So, my background is in economics, and currently I’m mostly working on the antibiotics market and the spread of antimicrobial resistance. 

Isaac Weldon:  
My name is Isaac Weldon. I am an assistant professor at CeBIL at the University of Copenhagen, and I’m also an investigator with the Global Strategy Lab at York University in Toronto.

So, the ecological, or socio-ecological approach is about looking at the relationship between humans as individuals or collectively as societies, and our relationship with the natural environment. So, we live in societies, and these societies interact with, co-evolve with and affect material, natural ecosystems and environments. Which in turn, also affect us and how we live. And so, for AMR, it’s about looking at microbes as part of this natural ecological basis of the world.  

Daniela Corno: 

We often think of AMR as something that only happens in hospitals or labs through overprescription of antibiotics or as a consequence of patients not using them responsibly. But as Isaac explains, it’s really part of a much more complex natural system. How do human interactions with the environment influence microbes and antimicrobial resistance? 

Ilaria Natali: 

Indeed, in the context of AMR, a socio-ecological perspective means also acknowledging that you know… antimicrobial resistance isn’t just a biomedical issue, but also an environmental and societal challenge. And so, this perspective highlights how human activities can alter, for example, the environment, and in turn, how these environmental changes contribute to the evolution and the spread of antimicrobial resistance. And if I may add, I find that this dimension of AMR has been understudied so far. 

Daniela Corno:  

As we’ve reiterated before, we need to be thinking of solutions and approaches to tackle AMR that fall under the One Health narrative. 

Isaac Weldon:  

Yeah, I think you know, One Health is so important for understanding the interconnection amongst human health, animal health and environmental health. You know, when animals are sick, it increases the risk of human disease. And when we don’t take care of the environment, we put ourselves at risk. And so, it’s so important to look at One Health and the health of these different domains. My one issue with One Health if I could say, is that in these beautiful Venn diagrams that we the overlap and the connections, I always wonder where the microbes are.  

Daniela Corno: 

We often think of One Health as this beautiful, all encompassing, interconnected system. Humans, animals and the environment, all overlapping in perfect harmony. But Isaac is right. Where are the microbes in all of this? It’s almost like we’ve been telling a story about One Health without including one of the main characters, and we can’t paint them as just the villain of the story of AMR.

Like Isaac and Ilaria explained earlier, the idea of a socio-ecological approach is about looking at the relationship between humans and our relationship with the natural environment. We need to learn to coexist with microbes. So, if we were to rewrite the One Health story with microbes front and center, what would that look like? 

Isaac Weldon: 

And so when we take a socio-ecological approach and we focus specifically on our relationship with microbes, it enables us to see how the human, animal and environmental interface is not fixed, but is actually contingent, and it changes in history, based on our—based on a lot of different things. Based on technological innovation, capabilities, material realities, but also crucially on our relationship with microbes.

So, what do I mean by this? If you go back 100 years, we didn’t have antimicrobials. We didn’t have intensive feed operations. It was—it was very difficult to bring so many animals into confined spaces. But with antimicrobials, with antibiotics, we are able to do that, and that transformed the way that we interact with animals but also transformed the way that we interact with our environment.

And so, if I can just add one thing to One Health, where it’s so important to look at these different domains, we also have to look at our relationship with microbes and how our changing relationship with microbes transforms the configuration of human, animal and environmental health domains. 

Daniela Corno:   

And as we look at these broader connections, it becomes clear that understanding the impacts of AMR from a human, animal and environmental perspective is just as important as understanding it from a biomedical perspective. Dr. Ilaria Natali’s research shows us a link between air pollution and AMR. What implications does that bring to policy? 

Ilaria Natali: 

So, I would say the main takeaway from this research is that clean air initiatives and air pollution reduction policies represent powerful new tools that policy makers should exploit, should leverage in the fight against AMR. Since air pollution can carry important quantities of antimicrobial resistance, bacteria and genes, governments should enforce strict air pollution standards as part of their AMR mitigation strategies.  

Daniela Corno:  

Air pollution is a major problem because it harms human health the environment and contributes to global challenges like AMR. And this is a perfect example of the environment and AMR going hand in hand. Clean Air initiatives and stricter air pollution regulations should be used as tools to tackle AMR. Since air pollution carries resistant bacteria in genes, reducing pollution can help slow the AMR spread. 

Ilaria Natali: 

Let me also add that the existence of a causal relationship between air pollution and AMR has also important implications for the cost-benefit analysis of air pollution control policies, because any—obviously, any existing analysis in this sense, does not take into account the impact of that air pollution has on AMR, and this means that the existing estimates on the economic cost of air pollution is likely to be just a lower bound. 

Daniela Corno:   

According to a World Bank publication, air pollution costs the globe an estimated 8.1 trillion dollars in 2019, equivalent to 6.1% of global GDP. More than 95% of deaths caused by air pollution occur in low- and middle-income countries. Including AMR in air pollution policies is crucial for making effective policy decisions.

If we leave AMR out of the equation, then we’re trying to tackle all these interconnected issues without seeing the full picture. This idea of AMR being linked to air pollution is a great example of socioecological dynamics at play. This challenges the way we typically think about AMR, showing it’s not just a biomedical issue, but rather something shaped by our environment and our policies.  

Ilaria Natali:  

You know, traditionally, we have been blaming always the excessive use of antibiotics for rising AMR rates, and this has led to policy responses that are almost exclusively focused on measures such as antibiotic stewardship and pharmaceutical innovation.

Now, of course, these types of measures are very important, but they necessarily overlook these environmental, these socioecological dimensions of AMR. By adopting a sociological perspective, we challenge this narrow view, and we try to push the discussion beyond antibiotic use, to indeed incorporate these environmental and sociological components into policy making?  

Isaac Weldon:   

Yeah, I would. I would totally agree with that, and just maybe to add on that, what it really helps to do is contextualize stewardship and contextualize innovation within a broader understanding of our co-evolving relationship with microbes as one earth system, but then also all these other planetary systems that affect antimicrobial resistance. Like Ilaria’s research is demonstrating with air pollution.

And I would just add on to this you know, it’s so important to get new drugs, but to only do that, to continue just fighting fire with fire is not a sustainable—it’s not a sustainable path. Inherently, it’s not sustainable rather than trying to find ways to live more harmoniously with natural environments, including microbes, while crucially maintaining our ability to destroy the harmful ones that cause disease and illness.

And that includes things like transforming the way we think about health and wellbeing, so that people don’t get sick in the first place, so that they don’t demand antimicrobials in the first place. So, looking beyond just biomedical stewardship, looking beyond just innovation, to think more broadly about the social systems in which we live, as well as the relationship between those social systems and the natural environment. 

Daniela Corno:  

The war on AMR is not working. A previous paper by Isaac introduces the very same perspective that instead of viewing our relationship with AMR as a war we must win. We instead need to rethink this relationship and design stronger institutions that sustainably manage the social and ecological factors accelerating AMR. And to shift AMR policy beyond the biomedical lens, we need to get policymakers to see the full picture, recognizing the broader environmental and societal challenge.

A recently published study in The Lancet estimates that antimicrobial resistant pathogens will kill more than 39 million people by 2050. How far down the causality line do we have to go in order for there to be enough evidence to instigate action? 

Ilaria Natali:  

But typically for high-cost interventions or major regulatory shifts, policy makers demand robust causal evidence that quantifies the impact of specific intervention. And this is where research providing causal estimates, for example on the relationship between air pollution and AMR can be crucial, because by demonstrating that air pollution is not just correlated but actually contributes to the spread of resistance, we provide a stronger justification for integrating AMR into environmental policy frameworks. 

Isaac Weldon:  

Yeah, I mean just to add on to that. Of course there’s always going to be uncertainty. That said, like we’re—we’re for some reason willing to go down the path of you know—we’re uncertain what kind of new innovations—like the allure of new drugs that’s an uncertainty. An uncertain path we’re willing to go down. We have so much evidence based on centuries of public health about what works to keep people healthy: prevention, water, sanitation, hygiene. These we know are the most cost-effective ways to alleviate the burden of AMR.

There’s really no question that if—you know if we improve these conditions, these prevention measures will have an impact on this global health crisis. And so it’s—it’s partly about uncertainty, and causality pathways, but it’s also about priorities and you know—it’s very—it’s quite sexy to say, you know, we have a new drug, this is going to solve the problem. It’s very hard to you know—you know… prevention is not really tangible… you can’t count [it]. You know how much innovation comes. Like innovation you can count. You know this many new drugs with prevention—you can’t—it doesn’t have the same kind of political allure. The same kind of attraction. So, yeah, it’s about uncertainty, causality…but also about political priorities, I think.  

Daniela Corno:   

But where do we go from here? How do we take these new conceptions and actually push them forward into policy and action? What needs to happen next to make these broader perspectives part of a global AMR response? 

Isaac Weldon:  

I think we’re on the right path with these kinds of conversations that are more exploratory and illuminating. And I think this, this kind of bleeds into where I think the conversation is going. But also, you know, related to that, that last point on impacting policy, where it—it seems to me that we have enough information to act. The challenge is getting the action to happen. These conversations are crucial for raising awareness. But I would maybe… a little bit more cynically argue that that information or lack of information is not the issue here. 

Ilaria Natali: 

It’s true that more and more information is becoming available. But I believe that still continuing, of course, to research on these topics is very important. We still need to push research further and further. And one thing that I find would really help in this sense, is also, for example, strengthening data collection. Making AMR data easily accessible and publicly available. I also wanted to add that, I believe it’s important also to encourage global and cross sectoral cooperation.  

Daniela Corno:  

It’s true that there’s already an overwhelming amount of evidence that air pollution affects human health, and we already know AMR is a global crisis. The challenge is ensuring this evidence doesn’t fall through the cracks. However, it’s clear that these connections offer new opportunities to bring together different sectors.  

Isaac Weldon:   

I don’t want to be too cynical, but like we know that air pollution is bad for our health, and so I question you know—I think it’s so fascinating and important, scientifically to understand these different pathways of AMR. But is this the missing piece of the puzzle that’s going to push policymakers to do more with air pollution? When we know we have so much evidence that air pollution is bad for us already. And likewise, you know—we know that AMR is amongst the leading causes of mortality worldwide. Isn’t that sufficient to—to feel like, compelled to act and and like adding on this—this information that also air pollution and AMR are kind of related and need to be addressed in concert. You know, on one hand, yeah, that creates bridges and possible partnerships across different disciplines for advocacy to make policy change. However, I think in isolation, both of them already have compelling arguments to—for action. And so whether, whether putting them together crosses the tipping point, I don’t know. I think that’s up for debate. But I do think that these kinds of conversations are important, both scientifically and for policy to demonstrate the connections. 

Ilaria Natali:  

Well one small one [comment]…I would just add that, I believe that creating more and more interdisciplinary research centers for example can help a great deal in this sense. Like you know bringing economists, epidemiologists, physicians, individuals with a biomedical background altogether can provide complementary insights and generate positive spillovers. 

Isaac Weldon:  

I do—I do think that you know, this kind of this kind of research is—is so fruitful in improving our understanding of the way that the world works, the way that our societies and their interactions with the natural world works. What’s missing, I think, or maybe to push the envelope, is that in creating these connections, in building these bridges across disciplines, I think we also need to turn our eye to also look at how these kinds of bridges and this new information can feed into policy change. So, it’s not just, “oh, this is really fascinating”. How does this actually change the way we think about action in you know these—these really trying times that we live in. 

Daniela Corno:   

That was Dr Isaac Weldon, investigator at the Global Strategy lab and assistant professor at the Center for Advanced Studies in Bioscience Innovation Law, based at the University of Copenhagen. And Dr. Ilaria Natali, post-doctoral research fellow at the Toulouse School of Economics. Thanks for tuning in to another episode of unpacking AMR. To find more resources about the topic we discussed today, visit our podcast page at www.globalstrategylab.org\unpackingamr. And remember, AMR is more than drugs and bugs.