Will the UNGA meeting on AMR deliver results for the global south?

A high-level meeting at the United Nations General Assembly later this week aims to put the growing threat of drug resistance back in the spotlight — but translating a political declaration into action will require global coordination and better incorporation of the needs of low- and middle-income countries, experts say. Antimicrobial resistance, or AMR, renders essential drugs such as antibiotics ineffective, making it one of the world’s most pressing global health threats. A landmark study published last week estimated that from 2025 to 2050 there will be 39.1 million deaths attributable to AMR, and 169 million deaths associated with AMR, with the highest mortality rates affecting countries in the global south. But despite the greater risk to low- and middle-income countries, the focus of international agreements so far has been centered around the needs of high-income countries, critics say. A viewpoint published in The Lancet earlier this year warned of a “great divide” in the priorities and agendas of countries in the global north and south. “The G7 and G20 dictate where the main interventions globally are happening,” said Marc Mendelson, lead author of the viewpoint and a professor of infectious diseases at the University of Cape Town. The vast majority of funding in AMR has focused on the research and development of new antibiotics, said Mendelson, neglecting investments in mitigation interventions such as infection control, diagnostics, and vaccines — priorities of lower-income countries, “which get a much, much smaller percentage of the pie when it comes to investment.” While the previous high-level meeting on AMR in 2016 saw the unanimous adoption of a political declaration, geopolitical divisions were on display ahead of the meeting this month, with the silence procedure — a process wherein countries are assumed to agree with a draft resolution if they remain silent — broken twice before a consensus was reached. The need for better data, more access, and stronger public health systems In comparison to high-income countries, there are “vast differences in availability and affordability of tools in low- and middle-income countries, where they are needed the most,” said Dušan Jasovský, AMR pharmacist at the Médecins Sans Frontières Access Campaign. But a dearth of data in many lower-income countries, both on circulating pathogens and the availability of tools such as antibiotics to counter them, makes the scale of that divide difficult to quantify, hampering advocacy and effective policymaking. Concrete steps to monitor and quantify that antibiotic access gap is something that is likely to be missing from the final declaration, Jasovský said. A draft of the declaration published earlier this month contains some language on strengthening laboratory capacities and a commitment to improve access to diagnosis. But to make this commitment meaningful, there is a greater need for “significant international funding and focus on evidence gaps and locally identified needs,” said Jasovský — “starting with access to quality-assured microbiology, for both clinical care and surveillance purposes.” But while surveillance will show the scale of the problem and could help to drive policy, ultimately AMR cannot be addressed in lower-income countries without tackling the high burden of disease. That means that “we need to interlink everything with the SDGs [sustainable development goals], because so much of this is about reaching SDG targets,” Mendelson said. A series of papers published in The Lancet found that basic interventions such as universal access to water, sanitation, and hygiene infrastructure, infection control in hospitals, and childhood vaccines could prevent an estimated 750,000 deaths associated with AMR each year in low- and middle-income countries. An additional 20% of providers reliably practicing hand hygiene would alone prevent 6.2% of all AMR-associated mortality in low- and middle-income countries. Too many antibiotics, or not enough? Public health care expenditure remains well below targets in most low- and middle-income countries, however. The 2001 Abuja Declaration for example saw African Union member states commit to allocating at least 15% of government budgets to health care, but analysis found that two decades later only two countries — Cape Verde and South Africa — had managed to meet this goal. In India, spending on health care has remained stagnant and by some measures has decreased as a percentage of the overall gross domestic product. Coupled with the country’s position as a major producer of generic drugs, this means that antibiotics are readily available even when other health interventions are not. Despite attempts to regulate usage, antibiotics are widely available over the counter; one study found that 60% of patients visiting an emergency department had first self-prescribed antibiotics. Overreliance on antibiotics is often cited as a major cause of growing drug resistance because antibiotics kill off all but drug-resistant bacteria, creating an environment where they can thrive and multiply. But Leena Menghaney, a lawyer specializing in Indian pharmaceutical policy, said that this excess issue needs to be reframed as an issue of access. Most rural health care centers lack adequate diagnostic tools, she said, meaning that when a patient presents with a fever the cause is impossible to determine — leading patients to look elsewhere for solutions. “One of the reasons why people turn to the private sector in India, where a lot of the excess use of antibiotics happens, is that people don't have access to a very strong public health system,” she said. And while some antibiotics may be readily available, others are not. Public sector hospitals and health care providers often struggle to procure a sustainable supply of basic drugs such as penicillin, said Menghaney, which are less profitable for the private sector to manufacture. When basic antibiotics used for the treatment of everyday infections, or “access” group antibiotics, are unavailable, patients are forced to turn instead to the private sector and “watch” and “reserve” group antibiotics — last-resort antibiotics that should only be used for cases where basic antibiotics do not work. The World Health Organization recommends that 60% of a country’s antibiotic consumption should be from the access group, but in India, an estimated 59% is from the watch group. To ensure that watch group antibiotics are reserved for cases that really need them, we need to diversify the supply chain for basic antibiotics, Menghaney said, and create a system of pooled procurement where the central government oversees supply. How will the political declaration change things? After the last high-level meeting on AMR in 2016, most countries worked to develop national action plans to combat AMR. But according to a self-assessment survey, by 2022 only around 10% of countries had allocated the budget necessary to implement their plans. This is hardly surprising when many countries in Africa require financial aid to develop their plans, said Mirfin Mpundu, the director of ReactAfrica, a global network of AMR experts and stakeholders. “If a country is telling you I don't have money to develop a plan, how do you expect it to implement a plan it has developed?” he said. When it comes to the upcoming high-level meeting, “The elephant in the room is around financing,” Mpundu said. But AMR is a global problem, he said, and countries need to be financially supported regardless of the level of progress they are at. “We are only as strong as the weakest link,” he said. The draft resolution aims to mobilize $100 million by 2030, which experts have said falls far short of what is needed. One of the major steps forward has been the inclusion of an independent advisory panel, which can lead policy in the same way the IPCC leads the climate agenda, Mendelson said. But he cautioned that the independence of the panel is something “we need to keep an eye on.” Some experts expressed concerns that panel members with vested business interests, such as in the use of antibiotics in the agri-food industry, may seek to influence outcomes. Currently, commitments made in the draft declaration fall short of previously agreed targets such as those made in the Muscat Ministerial Manifesto, which set a goal of reducing antimicrobials used in agri-food systems by 30% by 2030 — something which is notably missing from the draft. “A number of those recommendations [from the Muscat Manifesto] have not been taken up. And that's really a bit concerning,” Mpundu said. Experts said however that what matters more than the political declaration agreed upon this month is how we move forward afterward. “I think the greatest threat is that everyone sees the UNGA high-level meeting like it did in 2016, as an endpoint,” Mendelson said. Ultimately, Mpundu said, AMR is a complex, multifaceted problem that will require a cross-sectoral approach, at both the global and country level. “The problem is that we, for a very long time, looked at it scientifically,” he said. “But there are so many issues that have an impact on antimicrobial resistance: social, economic, religious.” Each country needs to create a dedicated body to coordinate across sectors, he said, with “backing politically, legally, legislatively, financially.” Otherwise, he warned, “we will not go anywhere. We will be back in the next five years and hoping for another resolution.”