By Giorgia Dalla Libera Marchiori
At the end of September 2024, world leaders, civil society organizations, and experts gathered in New York for the 79th session of the United Nations General Assembly (UNGA). Among the many meetings and points of discussion, antimicrobial resistance (AMR) was in the spotlight.
AMR refers to the ability of pathogens (bacteria, viruses, parasites, and fungi) to become resistant to medical treatment. Antibiotic resistance, meaning the capacity of bacteria to survive treatment with antibiotics, has been referred to by experts in the field as the “silent pandemic” - an appropriate term when looking at the numbers.
In 2019, there were an estimated 4.95 million deaths associated with bacterial AMR, which is more than half of the total deaths due to bacterial infections. The UN reports that AMR-associated deaths could increase to 10 million each year by 2050 if no action is taken. This death count would be equal to the entire population of countries like Sweden, Cuba, or South Sudan.
Recognizing the urgency and scale of the issue, at this year’s UNGA, the first global target was set, aiming to reduce the number of global deaths associated with AMR by 10%. And yet, achieving such a target will not be easy. Not because the commitment is not genuine but because AMR is the product of a global system that incentivizes excessive production and consumption of medications.
Production and consumption of medicines globally are increasing exponentially. In 2023, global sales reached 1.48 trillion. Access to medication and other pharmaceutical products, such as vaccines, is fundamental to cure and prevent illnesses. Greater access to medicine can be seen as a positive outcome of moderation and the liberal market. However, overproduction and overconsumption of medications negatively impact both people and the planet, as exemplified by the AMR crisis.
To understand and tackle AMR, and especially antibiotic resistance, we must first look at the underlying consumptogenic system. This refers to the web of “institutions, policy, commercial activities and norms that incentive and reward excessive production and consumption” of antibiotics, with consequences beyond human health that impact people and the planet.
Unpacking the system behind the AMR crisis
Overconsumption and misuse of antibiotics are both highlighted as drivers of AMR. Indeed, globally, 50% of antibiotics use is inappropriate, a situation that is facilitated by legal or illegal over-the-counter availability, which means antibiotics can be purchased without a doctor’s prescription.
However, it is not humans who are the primary users of antibiotics. More than 70% of antibiotics are used in animal farming. Why? To prevent diseases and boost animal growth. In fact, in intensive farming, large numbers of animals are confined to small spaces where hygiene may be far from ideal, increasing the chances for infections to develop and spread. Small doses of antibiotics are administered to animals to prevent infections and facilitate growth, especially when weaning is cut short. These doses are smaller than the doses needed to treat an active infection.
This low and prolonged exposure to antibiotics creates the perfect conditions for resistant bacteria. Since 2012, colistin (also known as polymyxin E), an antibiotic heavily used in animal farming, has started to lose its effectiveness. This prompted 150 medical professionals to sign a joint letter asking European Union legislators to ban the use of colistin for food production and reserve its use for humans.
Moreover, high livestock consumption of antibiotics results in contaminated manure and urine, bringing antibiotics directly into contact with the environment. Such spillovers pollute water and soil, with consequences that are difficult to predict. For instance, some scientists found, by mimicking conditions in the lab, that a high concentration of antibiotics in freshwater ways may contribute to greenhouse gases (GHG) emissions by impacting bacteria methane metabolism. This would add to the 32% of human-made methane emissions coming from manure and enteric fermentation of animal farming which antibiotics overuse contributes to maintain.
When it comes to GHG emissions, we cannot ignore the implications of one country being the leading producer and exporter of antibiotics globally. Indeed, almost 42% of antibiotics come from China. Since global trade of goods relies on fossil fuel-based transport, the CO2 emissions due to China’s antibiotics global distribution adds to the already high emissions of its pharmaceutical industry, which was 56.56 million tons of CO2 in 2016 – more than what was released by Hong Kong in the same year.
The industry has also been found to contribute to water and soil pollution, exacerbating the known effects of AMR with unknown consequences for the overall ecosystem. For instance, good soil bacteria might be impacted by antibiotics, which consequently could affect food production.
Inequities also exacerbate the AMR crisis. A study found that the overuse and misuse of antibiotics by small farmers is due to a lack of economic and other means to access veterinary support. Therefore, even when regulations are introduced to reduce antibiotic use in animal farming, small farmers may continue to support the status quo because they do not have any other option if they want to remain economically viable.
Farmers are also more likely to get in contact with resistant bacteria, making them vulnerable to life-threatening infections. Inequities in healthcare access may also lead people to self-medicate, overusing or misusing antibiotics acquired over-the-counter at physical and online pharmacies. This practice does not just feed the AMR crisis but also causes other medical conditions to emerge or delays proper diagnosis.
Where do we go from here?
While antibiotics are essential medicines that can save lives if they are used properly, current overproduction and consumption are threatening people’s health in different ways, leaving some groups more vulnerable to the consequences of this consumptogenic system. Considering such a system, what does the outcome of the 79th UNGA AMR meeting tell us?
The political declaration that world leaders agreed upon, which included the target of a 10% reduction in global AMR-associated deaths, acknowledges the importance of a multisectoral and interdisciplinary approach to tackle the AMR crisis. The declaration also mentions the importance of applying a One Health approach and incorporating equity considerations. There is even a commitment to ensure “prudent and responsible” use of antibiotics in animals and agriculture. These are all good signs for a more holistic approach to tackling AMR.
However, when the roots of the problem are in the system, it is that system that needs to be changed. The goals of profit accumulation and continuous economic growth drive the current economy. This obsession with profit and growth requires overproduction and overconsumption of goods and services to sustain itself.
As articulated above, overproduction and overconsumption go beyond the current AMR crisis and contribute to other health and environmental issues. Therefore, not questioning the drivers of our economy puts this political declaration and its 10% target at risk of falling short. Especially considering that the pharmaceutical and industrial farming industries are powerful actors in global governance who want to maintain business-as-usual, no matter the consequences for people and the planet.
With countries “looking forward to the upcoming 4th Ministerial Conference on AMR to be held in November 2024 in Saudi Arabia under the theme ‘From Declaration to Implementation - Accelerating Actions Through Multisectoral Partnerships for the Containment of AMR’”, civil society organizations and experts should not just push for concrete actions concerning AMR alone.
There is scope here to partner with many other civil society and expert groups advocating for broader system change that would help to address many health crises, including AMR. By overcoming fragmented and siloed action and creating a cohesive movement for change, we can counterbalance the power of commercial actors and states that directly profit from antibiotic overuse.
I believe that real change can happen when we can join as a global movement of people caring for different causes but united to achieve the same goal: planetary health equity, “the equitable enjoyment of good health in a stable Earth system”.
About the author - Giorgia Dalla Libera Marchiori is a PhD candidate at the Planetary Health Equity Hothouse. Her PhD investigates health philanthropy’s research agenda and its implications for achieving planetary health equity. Originally trained as a biomedical scientist, Gio worked with various non-profit organizations focused on global health and sustainability. Gio participated in the WLPH digital leadership academy in 2022.
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