Antimicrobial Resistance: A Catastrophic (and Neglected) Biological Threat
With AMR being a global priority, biosecurity-type policy around resistance may be part of the solution.
Prior to and post the COVID-19 pandemic, the notion of a catastrophe, specifically a biological one, was isolated to the kind of events we would see in films. The population-ending, mass casualty pandemic that rips across the globe is often what comes to mind. Although that is still possible, if history has shown us anything, it is that pandemics and the biggest biological threats are less likely to have the highest mortality rates and that, ultimately, catastrophe can mean many things. But catastrophe can also be slow-burning—the neglected issue we have had decades to combat yet still opt to drag our feet over as it kills millions a year. Through the COVID-19 pandemic, we have seen a shift in the landscape of biological threats and how we frame them. Biosecurity, as a term and concept, has been broadened to encompass all biological threats and their far-reaching impact. As we consider these threats and our efforts not only to prevent them but also to prepare for them, we should consider a holistic perspective. Traditionally, we have thought of biological threats as a spectrum: intentional, accidental, and natural. Too often, though, we focus only on specific threats, the high-impact if lower-probability ones that have historically garnered a lot of media attention.
Despite the importance of readiness for all events, low or high probability, there are some we frequently neglect. Antimicrobial resistance (AMR) is one in particular that we seldom prioritize or discuss despite its growing impact and the hurdles we face in response. The antibiotic apocalypse sounds like something from a film or comic book, but the reality is not that far off. According to the World Health Organization (WHO), AMR is one of the top global public health threats and, in 2019, was directly responsible for 1.27 million global deaths and contributed to the deaths of 4.95 million individuals.1
AMR is a biological threat that indiscriminately affects people and regions despite income levels; however, in such regions the threat is “exacerbated by poverty and inequality, and low- and middle-income countries are most affected.”1 AMR doesn’t just affect human health but has farreaching implications for animals and plants alike. Its impact affects economies, from more expensive health care stays to food insecurity. The authors of one report predicted that “by 2050, annual global GDP [gross domestic product] would fall by 1.1% in the low-impact AMR scenario and 3.8% in the high-impact AMR scenario. Low-income countries would lose more every year leading up to 2050, with the loss exceeding 5% of GDP in 2050.” 2 In the United States alone, the Centers for Disease Control and Prevention has reported that each year there are 2.8 million serious infections caused by resistant bacteria, which result in 35,000 deaths.3 AMR is a tough issue, however. It is not simply the overprescribing and misuse of antimicrobials in humans and animals, but the pressure physicians face to prescribe antimicrobials for likely viral infections from fear of bad reviews (even if patients do not leave such reviews) or medical tourism because of the high cost of US health care.4 Additionally, we have a broken market for drug discovery, and incentives to develop antibiotics and new drug classes are few and far between. AMR requires that we dig more into the outbreaks and clusters that can tell us why resistance occurs, how transmission can be halted, and reveal the barriers to change.
A Shifting Mindset and a Call to Arms
AMR is not just a public health crisis but a larger issue with national, economic, and food security ramifications. That the issue is complex is no excuse, although it explains why we systematically struggle to get our arms around it. In many ways, AMR is a wicked problem. In policy, this term is used for complicated or likely impossible issues that are interconnected with constraints and often lack clarity. Simply put, these issues are practically impossible to solve, and our best bet is to infuse them with a mixture of agile and holistic measures that are likely to meet with longterm rather than short-term success. This also requires us to prioritize AMR as the actual threat it is. While we battle H5N1 in dairy farms across the United States, the boom and bust of pandemic prevention funding has become glaringly apparent. But imagine if we used AMR as the perfect opportunity to build a sustainable response to a pandemic that never really went away.
As with COVID- 19, we have learned to live with AMR; however, its threat is only becoming more complex, nuanced, and expensive. Pulling from our biosecurity and biodefense strategies, we can start addressing the problem through robust surveillance measures and more extensive collaborations to strengthen dialogue and partnerships. What if we treated AMR as the biosecurity and biodefense threat it is, using the tools we have already strengthened post pandemic, such as biosurveillance, artificial intelligence (AI), and forecasting? For example, how can we address the threat of AMR when there is such an asymmetry in data?
In 2015, the WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) program to assess the true incidence and prevalence of AMR and our consumption of antimicrobials. In a 2022 report, they found that the “median reported rates in 76 countries of 42% for third-generation cephalosporin-resistant Escherichia coli and 35% for methicillin-resistant Staphylococcus aureus are a major concern.” For urinary tract infections caused by E coli, 1 in 5 cases exhibited reduced susceptibility to standard antibiotics like ampicillin, cotrimoxazole, and fluoroquinolones in 2020.”5
GLASS is the first step in approaching AMR. As we work to enhance biosurveillance across the globe using the lessons learned from COVID-19 and tackle our glaring gaps in pathogen early warning systems, we should also include resistant bacteria and track specific genes that are spreading. Moreover, we should harness the power of AI to help develop new antimicrobials and predict climate change’s effect on AMR. Additionally, let’s not forget the use of policies and incentives to drive the drug discovery we so desperately need. From climate change to conflict, some stressors amplify AMR, and yet we often consider the threat of resistant bacteria a secondary, almost passive, issue.
Again, the framing of this issue is the needle we hope to thread. Biosecurity as it relates to health can quickly bring negative ramifications, and as we work to prioritize AMR, we must choose our strategies and framing carefully. This biothreat has national security aspects, but perhaps we can manage these through partnership and reframing. We cannot address AMR solely through biosecurity or biodefense— it requires a balanced partnership with public health, agriculture and farming, and private industry. Perhaps this neglected, wicked issue could be the perfect opportunity for global partnerships and innovative global health.
