Being asked to coordinate a paper for the Journal of Law, Medicine & Ethics wasn’t on my academic bingo card for the year, but like a lot of things in recent years, I’ve come to expect the unexpected. The paper in question is part of a special edition entitled Addressing Antimicrobial Resistance through the Proposed Pandemic Instrument. It has a great series of papers addressing a range of pandemic issues, the threat of antimicrobial resistance (AMR), how a pandemic instrument (meaning an international instrument like a treaty) can address pandemic prevention, and why AMR needs to be part of that.
Why are we talking about AMR and pandemics?
Antimicrobial resistance has been called the “silent pandemic,” since it currently causes substantial but often largely unrecognized harm around the world, and the scope of the problem is only getting worse. While peoples’ first thoughts about pandemic risks almost invariably jump to new viruses (which are absolutely important too), the ongoing pandemic of AMR is killing huge numbers of people, affecting countless lives and livelihoods, compromising advances in healthcare, impacting animal health and welfare, and having a tremendous economic impact. It doesn’t get much press, but it’s one of the biggest global health threats we are currently facing. If we don’t act aggressively, it’s going to get much worse.
The special edition of the Journal of Law, Medicine & Ethics has lots of great information about why AMR needs to be in the pandemic instrument, governance issues related to that, what a pandemic instrument might achieve, and what barriers might be present. If you’re interested in this area, I’d recommend checking out those articles.
Here I’ll comment on the article that we wrote for the series, entitled “Governance Processes and Challenges for Reservation of Antimicrobials Exclusively for Human Use and Restriction of Antimicrobial Use in Animals“. We were asked to write about how restriction of antimicrobial use (AMU) in animals and designation of certain antimicrobials exclusively for human use could be built into an instrument. However, we took a bit of a different tack, partly because governance isn’t my area, but more because there are a lot of nuances to the issue that need to be considered by people with expertise in governance.
Ultimately it sounds simple: just use fewer antimicrobials.
But that’s just part of the story, and there are many related issues. If we don’t dive into those, we can end up with ineffective or impractical efforts that may not be optimal, or worse may not help at all, or even worse yet may cause unintended negative consequences. We’ve seen all those outcomes in the past.
Why? The short answer is, it’s complicated.
Too often, the approach to AMU in animals is focused more on sound bites than science and practical measures that will actually achieve anything positive. That’s partly because of the complexity of the larger problem, partly because of big data gaps, and partly because of a lack of understanding of key issues within the problem.
I don’t want to take the lazy way out and just say “read the paper if you want more details” but I recommend you do if you want to understand the area more. It’s far too complex to summarize neatly in a blog post, but here are a few key points to consider as a start:
- “Antimicrobial use” encompasses a wide range of uses, including treatment, metaphylaxis, prevention and, in some countries still, growth promotion. The issues differ between those, but even within each category, there can be lots of variation leading to different issues. For example, it’s common to hear “Antimicrobials shouldn’t be used for prophylaxis in animals.” However, prophylaxis is very broad, including things such as medication of thousands of healthy animals at once based on historical use more than data, or a single dose of antibiotics in an animal undergoing a high-risk surgical procedure (where infection is a reasonable concern and would result in a longer therapeutic course). We want to reduce prophylaxis as much as possible but there are some situations where it’s needed for animal health and welfare reasons. There are also situations where use is unnecessary, done based on fear or habit versus evidence, or used in lieu of good management practices. We definitely want to curtail use in those cases.
- Ideally, we’d have all antimicrobial use in animals driven directly by a veterinarian. That works in areas where there is good access to veterinary care, but it doesn’t work everywhere, at least not at this point. We need to improve veterinary access and animal health systems in parallel with efforts to reduce AMU and bring all AMU under the auspices of a trained veterinarian (or allied health professional). “Stop over the counter access to antimicrobials” makes sense in many places, but in some, it would significantly compromise animal health and welfare. It’s even a challenge in some parts of Canada that are under serviced in terms of access to veterinarians.
There are many similar components that sound simple at first, but get much more complex when you delve into them. Failure to understand that complexity dooms approaches to address the issue of AMR.
At the same time, there are lots of potential interventions, some of which are amenable to an international instrument like a treaty. We can’t solve this problem with a treaty, since there’s no single thing that can eliminate the scourge of AMR. However, the way we will solve the problem is through myriad interventions by myriad groups, each providing a small piece of the greater prevention puzzle. An international instrument can be a key part of that by driving some changes and by emphasizing that this is an issue that needs to be addressed across the globe.