Could US foreign aid cuts fuel a superbug crisis?

The retraction of U.S. foreign aid could accelerate a superbug crisis, experts have warned, making many of the world’s diseases effectively untreatable. Antimicrobial resistance, or AMR, occurs when pathogens evolve resistance to the drugs commonly used to treat them — an emerging global health crisis that has drawn growing alarm from leading scientists. In 2019, the World Health Organization named AMR among the top 10 health threats faced by humanity, and a landmark study published in The Lancet last year predicted that there would be 169 million deaths associated with AMR by 2050. At last year’s United Nations General Assembly, global leaders approved a political declaration committing to increased action on AMR. But in the wake of U.S. foreign aid cuts and its announced withdrawal from WHO, global efforts to ramp up work on AMR will grind to a halt, said Ramanan Laxminarayan, an epidemiologist and founder of the One Health Trust. “The expansion of anything in the WHO is out of the question when their largest funder has just pulled the rug from under them,” he said. “Even the minimal activities in AMR will all have to start declining.” One of the most immediate impacts of the change in U.S. policy is the abrupt halt to health care services for infectious diseases such as tuberculosis. Disruptions to treatment can fuel drug resistance, allowing the disease to mutate, and the removal of control and surveillance programs would allow these new drug-resistant strains to spread undetected. A memo released earlier this month by Nicholas Enrich, then acting assistant administrator for global health at the U.S. Agency for International Development, predicted that as a result of the funding freeze cases of multidrug-resistant tuberculosis would increase globally by up to 32%, at an estimated cost of $40 million in treatment and diagnosis to the U.S. Enrich was subsequently put on administrative leave. The withdrawal of U.S. funding is also likely to hamper the ability of scientists and policymakers to track and contain the spread of drug-resistant malaria, said Philippe Guérin, a professor at the University of Oxford and the director of the Infectious Diseases Data Observatory. The spread — particularly in Africa — of resistance to artemisinin, which Guérin described as the “cornerstone” of current antimalarial treatments, “is extremely worrying because we don't have an alternative ready yet,” he said. Previous efforts to combat drug-resistant malaria have shown infection control to be essential. But programs supplying bed nets, drugs, and diagnostic tools, such as the President’s Malaria Initiative or PMI, have been terminated as part of the review on U.S. foreign aid. Analysis from the Malaria Atlas Project estimated that a halt of PMI-funded programs would result in 14.9 million additional malaria cases and 107,000 additional deaths within a year. PMI and the U.S. Centers for Disease Control and Prevention were also providing support for clinical efficacy trials to map local antimalarial resistance, as well as surveillance of molecular markers in the blood of infected individuals, Guérin said. These efforts have helped to inform policy in countries such as Rwanda and Uganda, he said, enabling authorities to take action by increasing control activities in specific areas or by switching to drugs that show less sign of resistance. “The point being on resistance is that if you don't know that there is a problem, then you can't act on it,” Guérin said. Too many antibiotics or not enough? As well as creating drug shortages and surveillance gaps, the funding cuts could also result in an overuse of antimicrobials, which can also fuel resistance. Removing funding for surveillance and diagnostics from one program will have a “snowball” effect on drug resistance across all diseases, Laxminarayan said. “If you have fewer diagnostics for malaria, it means that there'll be a lot of inappropriate treatment of children with fevers, because you're no longer able to tell whether they had malaria or they had a bacterial infection,” he said. Rahmeh AbuShweimeh, a pharmacist and AMR expert in Jordan, said that while there are laws in her country to prevent the overuse of antimicrobials, they are poorly enforced, meaning that “anyone can just enter any community pharmacy and get whatever antimicrobial over-the-counter, they can just buy without a prescription,” she said. AbuShweimeh was employed by the USAID-funded Medicines, Technologies, and Pharmaceutical Services program, which until its closure last month was working to strengthen pharmaceutical systems in 16 low- and middle-income countries. In Jordan, the program worked in collaboration with the national government to update guidelines and treatment protocols for common infections and surgical procedures in hospitals, to reduce unnecessary or inappropriate use of antimicrobials. The team also conducted awareness sessions in communities and schools and worked on water, sanitation, and hygiene, or WASH, initiatives to reduce overall infections. “I'm very proud of the work that we did because it's super, super, super important,” said AbuShweimeh. While her project was scheduled to end in 2025, another set to launch later this year has been put “on freeze” due to the USAID funding withdrawal, she said. “AMR is not a vertical disease — it's a sign of a poor health system.” --— Ramanan Laxminarayan, founder, One Health Trust Antimicrobial stewardship is part of Jordan’s AMR National Action Plan or NAP, a country-level plan in alignment with WHO priorities. But while many countries have drawn up NAPs, only an estimated 10% have the funding to implement them. Without U.S. support, AbuShweimeh said it would be difficult for the Jordanian government to fund these initiatives alone. “We really, really need to come together as a global community to halt the spread of AMR because it's really a threat to all of us,” she said, describing it as “a war between humans and pathogens.” In the agrifood industry, simultaneous overuse and lack of access to antimicrobials is a “double-edged sword,” said Kuastros Belaynehe, an Ethiopian AMR expert and former Food and Agriculture Organization employee. In the poultry and dairy sectors in particular, “there is a high pattern of antimicrobial resistance that is aggravated by overuse of antimicrobial agents,” he said. Until the January stop-work order, Belaynehe was working for the FAO’s Global Health Security Programme, or GHSP, funded by a $250 million grant from USAID. Taking a “one health” approach in recognition of the interconnectedness of human, animal, and environmental health, the program aimed to strengthen infection control measures and antimicrobial stewardship in agrifood systems, as well as build laboratory capacity for AMR surveillance and early detection of food-borne pathogens. In Ethiopia, part of that work involved supporting smallholder farmers to reduce antimicrobial use on farms. Before the GHSP was formally terminated earlier this month, it had already started to demonstrate positive results, with a measurable reduction in the use of certain antimicrobials, Belaynehe said. The first line of defense But the best way to prevent the overuse of antimicrobials is to prevent the need for them at all, experts agreed, by reducing the overall burden of infection. “Prevention is cheaper, but we need to invest in prevention to get a return on our investment.” --— Kuastros Belaynehe, an Ethiopian AMR expert “The most important interventions for AMR are, first and foremost, the prevention ones, of infection prevention control, water and sanitation, and immunization,” Laxminarayan said. In the wake of U.S. foreign aid cuts, “all three are at risk,” he said. When it comes to increasing drug resistance, the pathogens of most concern are gram-negative bacteria such as Klebsiella and Streptococcus pneumoniae, he said, which commonly affect newborns. The best way to prevent these infections is through health system interventions such as safe childbirth, WASH initiatives, and infection prevention in hospitals, Laxminarayan said. “AMR is not a vertical disease — it's a sign of a poor health system,” he said. But without U.S. support to strengthen these health systems, drug-resistant gram-negative infections will increase in many countries, Laxminarayan warned. “We should not be surprised if we see an uptick in child mortality because of the removal of funding, and that would be truly tragic,” he said. Training on how to prevent infections on farms was an important part of the FAO’s GHSP, Belaynehe said. After the program’s termination, “we are not really supporting the farmers or the producers on biosecurity, on improving good animal husbandry practice, so their farms will be really prone to disease,” he said. This would result in the increased use of antimicrobials and create a “chain reaction” of drug resistance, he said, making diseases harder and more expensive to treat. “Prevention is cheaper, but we need to invest in prevention to get a return on our investment,” Belaynehe said. “I hope the future of funding should be really focused on prevention, rather than just fighting the fire after it is happening.” Analysis released ahead of a high-level meeting on AMR at last year’s U.N. General Assembly found a return of $28 for every $1 invested if action on AMR was taken now. A 30% reduction in antimicrobials for livestock within the next five years could lead to a cumulative increase in global gross domestic product by $120 billion from 2025 to 2050, it estimated. Food security Failure to invest in AMR prevention could also result in long-term shortages and a rise in the price of commodities, Belaynehe said. Drawing parallels with the current crisis over egg prices in the U.S., he said that an explosion of drug-resistant pathogens could “definitely have implications” for the price of livestock-derived commodities such as eggs, meat, or milk. “I can expect such kind of things could be the consequence of not investing in prevention, biosecurity,” he said. “It is really a worthy investment in food security and also for public health.” According to Belaynehe, the GHSP in Ethiopia focused on three priority pathogens that can spread from animals to humans: E. coli, Salmonella, and staph infections. Drug-resistant pathogens from food sources pose a threat not only to human health but also to food security. The projection shows that drug-resistant pathogens could jeopardize the food supply of over 2 billion people by 2050. The hope was that more funding would be acquired in the future which would allow the FAO’s work to expand beyond the three priority pathogens into surveillance of pathogens that affect plant and aquaculture sectors too, Belaynehe said. That now seems unlikely. “It's unfortunate, we had a plan to do it in the future, but due to these budget funding cuts we will have difficulty,” he said. ‘An interconnected system’ Other donors support AMR initiatives through the FAO, said Belaynehe, but USAID was the main funder. Additionally, most development partners focus on one specific area of AMR, he said. For example, the Fleming Fund works mainly on strengthening surveillance. “USAID funding is critical, because the support is cross-cutting,” Belaynehe said. The cross-cutting nature of U.S. funding, and the abruptness with which it was withdrawn, have created additional pressure, experts said. “When you get one actor pulling out, it immediately reduces the effectiveness of someone else's money, because they're all depending on each other to do complementary things,” Laxminarayan said. For antimalarial initiatives, this interdependence means while one funder may have supplied the drugs or commodities, the delivery was funded by another, Guérin said. “And so you might have the drugs or the bed nets, but nobody to distribute them,” he said. The extent to which U.S. funding was embedded in many foreign aid programs will also make tracking the impact of that funding loss more complicated, Laxminarayan said. “It's an interconnected system, and you're ripping out so many parts of the system and destroying so many connections that it would be very hard to do this kind of [impact] analysis,” he said.