Gearing up against the AMR threat in Asia

The challenges confronted by the region that faces the greatest impact from the antimicrobial resistance crisis, and how it can deal with them, were addressed by a recent workshop held in Penang, Malaysia.

THIS increasingly grave problem brought over 70 national and intergovernmental officials, experts and civil society campaigners to the discussion table at the Regional Workshop on Antimicrobial Resistance in Asia, which took place on 24-26 June. The participants came from countries in South-East and South Asia, China and the Pacific region, as well as from international bodies including the World Health Organisation (WHO), Food and Agriculture Organisation (FAO) and World Organisation for Animal Health (OIE), the three agencies tasked with combatting AMR on a global level.

The workshop, which followed on from the first edition held last year, was co-organised by the Third World Network (TWN) and the South Centre with support from the Fleming Fund, an initiative of the United Kingdom Department of Health to assist developing countries in addressing AMR issues.

The developing world is expected to suffer the heaviest toll from AMR, with Asia being the most severely affected. The UK-sponsored Review on Antimicrobial Resistance has estimated that, at current trends, there would be 10 million deaths due to AMR globally in 2050. Of these, 4.7 million are projected to be in Asia, 4.2 million in Africa and almost 400,000 in Latin America.

Given the seriousness of the problem, action is urgently needed, and it has to take into account the multifaceted causes of AMR. One major factor behind the development of AMR is inappropriate prescribing and consumption of antibiotics by doctors and patients. Antibiotics are also misused for non-therapeutic purposes, such as to promote growth and prevent disease, in the livestock and aquaculture sectors. Further, antibiotic residues in soil and water can spread AMR through the environment.

Tackling all these different drivers of AMR demands a ‘One Health’ approach where the health of people is connected to the health of animals and the environment, as underlined by the Malaysian Deputy Health Minister Lee Boon Chye in his opening address at the Penang workshop. This approach should be collaborative, multisectoral and transdisciplinary, he said, with the goal of achieving optimal health outcomes for the human and animal sectors especially to preserve the efficacy of antimicrobial medicines.

The One Health principle is indeed reflected in the national action plans (NAPs) drawn up by various Asian countries to control AMR, which recognise the importance of coordination and engagement between the different sectors – human health, animal health and environment – involved. However, in practice, intersectoral collaboration has in many cases been limited, some of the workshop participants revealed, highlighting a gap that needs to be plugged to ensure more effective AMR containment efforts.

Besides enshrining the One Health approach, the NAPs have also been in line with WHO’s Global Action Plan on AMR and its strategic objectives:

(1) improve awareness and understanding of AMR through effective communication, education and training;

(2) strengthen the knowledge and evidence base through surveillance and research;

(3) reduce the incidence of infection through effective sanitation, hygiene and prevention measures;

(4) optimise the use of antimicrobial medicines in human and animal health; and

(5) prepare the economic case for sustainable investment, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.

In the workshop, participants outlined the measures taken by their respective countries on these five fronts. For instance, initiatives have been implemented in various countries to raise awareness of AMR among health professionals, farmers and the wider community. Separately, to promote rational use of antimicrobial medicines, regulations have been adopted by some countries to, among others, ban their use as livestock growth promoters, while clinical guidelines for physicians set appropriate prescription practices.

Infection prevention and control (IPC) is another priority; speaking at the workshop, former Yale and Australian National University academic John Beggs emphasised the need to ‘break the chain of contagion’ by interrupting the spread of resistant microbes. He advocated a broad definition of IPC, one which extends to dealing with the socioeconomic factors facilitating the spread of resistant bacteria, such as poor-quality infrastructure, low levels of societal governance and inadequate health expenditure.

Clearly, much has to be done to stem the proliferation of superbugs, but the anti-AMR drive is faced with several constraints. One common lament voiced at the workshop was over insufficient financing to support implementation of the NAPs that have been put together. Among other needs, funding is required to build national capacities for surveillance of trends in the development of AMR. This entails investment in human and technical resources such as training microbiologists and equipping microbiology laboratories. Many participants called for the setting up of a global fund to assist countries in countering the AMR threat and, at the national level, for governments to allocate dedicated budgets for AMR control.

The workshop discussions also brought home the need for increased focus on the environmental factors contributing to the spread of AMR. In the face of the greater attention devoted thus far to the human health and animal health areas, the environment sector was described by Noor Haza Fazlin Hashim from the National Hydraulic Research Institute Malaysia as ‘the missing piece in the jigsaw’ of anti-AMR programmes.

Moreover, focus should be directed not only at antibiotic residues in the environment but also at other possible environmental drivers of AMR such as pesticide and metal residues. In her presentation at the workshop, Nisanart Charoenlap, a scientist from Thailand’s Chulabhorn Research Institute, pointed to a study which revealed that the E. coli and S. typhimurium bacteria could increase their resistance in the presence of herbicides and antibiotics, while another study found that certain metals exhibited co-occurrences with specific antibiotic resistance genes.

Ultimately, as TWN’s Director of Programmes Chee Yoke Ling said during the concluding session of the workshop, AMR could be framed in terms of a ‘systems approach’. Accordingly, health systems need to be strengthened, and farming and food systems oriented away from the dominant but damaging industrial agriculture paradigm.

What it would take for more effort and resources to be channelled towards such measures is political will. There is thus a need to convey to senior decision-makers in government the sheer scale of the AMR threat.

In this regard, if money talks, then estimates of the economic costs of AMR highlighted at the workshop positively scream: Citing World Bank projections, Anthony So, co-convener of the UN Interagency Coordination Group on AMR, said that if AMR is unchecked, the world stands to lose up to 3.8% of its annual gross domestic product (GDP) by 2050, with an annual GDP shortfall of $3.4 trillion by 2030. – TWN                         

*Third World Resurgence No. 339/340, 2019, pp 36-37