The case for tackling antimicrobial resistance with a One Health approach

Antimicrobial resistance (AMR) is a naturally occurring phenomenon; microorganisms spontaneously mutate, rendering specific antimicrobial drugs ineffective against disease. However, the literature on AMR increasingly spotlights globalisation as exacerbating the issue. Researchers cite the exponential rise of international travel and trade—a symptom of today’s interconnectedness—as a mechanism for transporting resistance across borders. Antimicrobial misuse and overuse, particularly outside of human health (in agriculture, food production, and veterinary medicine), is also a major driver. The World Health Organisation (WHO) identifies AMR as a top 10 threat to global health, responsible for at least 700,000 deaths per year.

Image Credit: Unsplash

Ominous epidemiological findings such as these have spurred key policy actors into adopting the conceptual framework of global health security. Prominent examples include the G7 and myriad national governments, particularly those of high-income countries (HICs). This framing is ostensibly useful because it evokes fear. It acts as an international call to urgent action, generating an outpouring of funds in the process. This conceptualisation permeates public discourse, with former UK Prime Minister David Cameron considering “an almost unthinkable scenario where antibiotics no longer work, and we are cast back into the dark ages of medicine”.

His use of emotive language undoubtedly drew attention to AMR, resonating with powerful stakeholders; but it falls short of the holistic, multi-sectoral response needed. Most significantly, global health security over-emphasises the human component, with little regard for the animal, agricultural, and environmental sectors. With more antimicrobials now used in animals than human beings, this framing demonstrates a fundamental misunderstanding of the problem’s nature and scope. Thus, a One Health approach—which encompasses human, animal, and environmental health—would enable the development of more comprehensive policies to tackle AMR.

Considering the geo-politics

The One Health approach is not new. The term first appeared in 2003 after the severe acute respiratory syndrome (SARS) outbreak and has since risen in popularity, especially in the management of zoonotic diseases. Since then, the One Health framework has been adopted by some of the most powerful actors in global health governance, including the WHO and World Organisation for Animal Health (OIE). It seeks to bridge gaps between humans, animals, and the environment, recognising their increasingly interrelated natures in a globalised world. This approach, therefore, advocates for multi-sectoral collaboration spanning several disciplines, and stresses the need for integrated responses.

In doing so, One Health manages to sidestep many of the political pitfalls of global health security. By emphasising the need to work together—at the local, national, and global levels—the One Health approach avoids implicit narratives of AMR travelling from the Global South (‘Them’) to the North (‘Us’). The One Health framing is then more likely to resonate with policymakers in low- and middle-income countries (LMICs) as they are no longer centred as the source of the problem. This could help create political will to address AMR in the Global South, where the problem largely continues to be neglected. The political calculus here is important to successful global health governance, where nation states may have equal status but not equal power. Strategies that dissolve unspoken hierarchies, which are arguably remnants of colonial rule, are extremely helpful.

Using One Health to gain this LMIC support and encourage their involvement is crucial as the Global South tends to suffer the worst effects of AMR. This is generally due to poor water, sanitation, and hygiene (WASH) conditions, including open sewage systems. For example, in India—where AMR represents a major threat—39.84% of the population partake in open defecation practices. This increases the burden of infectious diseases, and hence the need for treatment with antimicrobials and selection for resistance. This process is enabled and further perpetuated by weak infrastructure. LMICs also tend to lack the robust infection prevention and control (IPC) programmes necessary to managing this, especially in relation to animal health.

The need for One Health in a globalised world

In the 21st century, with increased population mobility through travel and migration, and increased trade through liberalisation policies, carries important implications for AMR at the global level. For example, a 2019 study identified that poultry flocks in Pakistan were treated with 17 different antimicrobials. These were touted as serving prophylactic or therapeutic purposes. However, most frequently used was colistin, which is a last-resort antibiotic that should only be reserved for the treatment of multidrug resistant infections in humans, as recommended by the WHO’s AWaRe classification database.

Image Credit: Unsplash

A chicken battery farm

Practices such as these can have profoundly negative impacts, with drug-resistant microorganisms travelling up the food chain as humans consume meat. The environment could also suffer consequences as animals excrete waste, thereby contaminating the soil and groundwater. Poor sewage and water processing, typical of LMICs, can further exacerbate the problem by leading to the presence of drug-resistant microbes in surface water. This environmental effect then loops back to humans when the contaminated surface water is used for drinking. But, the implications of AMR are not limited to any one country, like Pakistan. The international gravity of the problem becomes clear when reflecting on the export of meat and other animal products to foreign countries. This is in addition to the movement of infected individuals across national borders—a behaviour made more accessible through the technological advances of globalisation.

Thus, a One Health approach is optimal as it centres the animal-human-ecosystems interfaces. This serves as a strong base from which to conceptualise policy solutions because it acknowledges the many upstream determinants of AMR, and how they interact with each other across sectors. A One Health perspective is a sharp contrast to global health security which over-emphasises the value of more downstream policies that only target humans. These generally include public awareness campaigns to limit inappropriate demand for antimicrobials. There is also a focus on optimising antimicrobial use through improved diagnosis and educating health professionals on best prescribing practices.

In response to the Pakistani example above, proponents of One Heath would instead advocate for solutions that consider the bigger picture. Policies might include banning the use of antimicrobials for animal growth promotion and inappropriate routine infection prevention. This approach appreciates the subsequent benefits to human and environmental health. Other measures could include improving access to non-medicated feed for farmers and hiring veterinary officers to ensure correct administration of antimicrobials where necessary. This is not to discount the value of human-oriented strategies, especially in LMIC where awareness of AMR remains low. However, these strategies achieve little in isolation without consideration for the animal and environmental components.

Room to change and adapt

Implementation of a One Health approach, in practice, is not without its challenges. Such challenges are particularly pronounced in LMICs due to scarce resources and competing public health priorities. Even where One Health style guidelines exist, success is limited by insufficient capacity for proper implementation. Attempts to develop national AMR surveillance systems have suffered a similar fate, with attempts to monitor antimicrobial use limited to human medicine. Therefore, building strong central regulation is an important prerequisite, which may be achievable through close collaboration with HICs that better manage AMR. Some policies may be generalisable, while others will have to be adapted in order to meet a specific country’s context and concerns. Local stakeholders should be engaged for this process to ensure proper enforcement in the long-term. Furthermore, pilot programmes and policy assessments can be used to determine whether a policy is (cost-)effective in a particular setting.

The ability of One Health to adapt to varying political and regulatory environments forms one of several advantages over global health security. The versatility of One Health, paired with the holistic, interconnected thinking that underlies the approach, will be extremely beneficial to tackling AMR in a globalised world. A refusal to shift from conceptual frameworks that overly securitise the issue will only stoke fear and nationalist sentiment, alienating LMIC policymakers in the process. As a result, the international collaboration necessary to manage AMR will become extremely difficult. Therefore, One Health—which recognises the inherently global nature of the problem—must instead guide future policy solutions. As more HICs endorse the concept, geo-political tensions will ease, thereby creating favourable conditions for collaboration with LMIC policymakers. In time, by centering animal-human-ecosystems interfaces, global health governance can more effectively tackle AMR.