The United Nations Environmental Programme recently released a report on the environmental dimensions of antimicrobial resistance called Bracing for Superbugs: Strengthening Environmental Action in the One Health Response to Antimicrobial Resistance. The report highlights how the environment plays a key role in the development, transmission, and spread of antimicrobial resistance.
Antimicrobial resistance (AMR) occurs when microorganisms become resistant to antimicrobials—such as antibiotics, antivirals, and antifungals—to which they were previously susceptible. Drug-resistant bacterial infections contributed to 1.27 million deaths in 2019, surpassing the toll seen by malaria or HIV that same year. The WHO considers AMR to be one of the top 10 threats to global health.
Anthony So, director of the IDEA (Innovation + Design Enabling Access) Initiative based in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health, is one of the five lead authors of the UNEP report. Following are his five key takeaways from the report.
The environment is key to tackling the global challenge of antimicrobial resistance.
Attention to AMR in the past has often focused on the human health and agricultural sectors, with less attention being paid to how environmental aspects, such as climate change and pollution, exacerbate antimicrobial resistance. With climate change, higher temperatures may drive up the incidence of antimicrobial-resistant infections in various ways, from the spread of disease vectors to geographies once more temperate to extreme weather patterns disrupting the environment. With pollution, antibiotics from hospitals, communities, and food production end up in municipal solid waste landfills and sewage and create conditions where AMR might develop and spread. Water, soil and air all play a role as environmental media that help transmit and spread drug-resistant microorganisms and genes. While more research needs to be done on the links between the environment and AMR, the report outlines actionable steps that we can take based on today’s evidence.
There are three main economic sectors that contribute heavily to AMR’s development and spread.
The UNEP report identifies pharmaceutical manufacturing, food production systems, and health care delivery as three sectors that have a significant impact on the environmental dimensions of AMR. Sources of pollution from these industries that can contribute to AMR include wastewater from hospitals, pharmaceutical waste, and run-off from crops and animal agriculture. Much of this enters and further taxes municipal waste streams from cities and communities, highlighting the need for intersectoral collaboration and commitment to address AMR as a One Health challenge.
Addressing antimicrobial resistance will require commitments across sectors.
Taking a systems approach, we will need to work across sectors to reduce the AMR burden and find alternatives to the over- and misuse of antimicrobials. Investments such as wastewater treatment must be adapted to the pharmaceutical manufacturing, food production systems, and health care delivery sectors to reduce antimicrobial pollution in the waterways. Environmental dimensions of AMR connect with issues like climate change, microplastics pollution, and WASH interventions, from which co-benefits from intervening may be found. Importantly, initiatives to address AMR and the environment, such as a global wastewater surveillance system, could also pay dividends in monitoring other emerging infectious diseases, as such efforts have been done for polio and COVID-19.
The consequences of not addressing antimicrobial resistance will be dire.
As the World Bank has projected, the economic toll of antimicrobial resistance, if unchecked, may result in a global GDP loss of $3.4 trillion annually by 2030, pushing 24 million more people into extreme poverty. This economic toll will come from disrupted trade, losses in livestock productivity, and higher healthcare costs—not counting the human toll in lives.
But we can invest now to prevent the worst of the consequences.
As the World Bank has proposed, investing just $9 billion a year to address AMR in low- and middle-income countries would result in substantial economic payoffs to low-income countries. The greatest absolute and per capita gains, however, would be seen by upper-middle-income and high-income countries, those in the best position to make this global investment. A UN report documented that nearly 90% of the $450 billion in global farm subsidies each year are harmful to health, the environment, and the climate, or worsening inequality by excluding smallholder farmers. We should look to repurpose such financing and find co-benefits as we look to invest in efforts to tackle AMR.