Governing Global Antimicrobial Resistance: 6 Key Lessons From the Paris Climate Agreement
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OPINIONS, IDEAS, & PRACTICE
Governing Global
antimicrobial consumed has global
implications. Some microbes have
Antimicrobial Resistance:
already developed resistance to all
known antimicrobials, meaning previ-
ously curable diseases have become
6 Key Lessons From the untreatable. If immediate action is not
taken, the effectiveness of these vital
Paris Climate Agreement medicines will continue to diminish, fur-
ther undermining modern medicine’s
ability to treat infectious diseases and
Isaac Weldon, MSc, Susan Rogers Van Katwyk, PhD, Gian Luca Burci, Dr Giur,
Thana C. de Campos, DPhil, Mark Eccleston-Turner, PhD, Helen R. Fryer, DPhil, perform essential medical procedures.1
Alberto Giubilini, PhD, Thomas Hale, PhD, Mark Harrison, DPhil, Stephanie The global spread of severe acute
Johnson, PhD, Claas Kirchhelle, DPhil, Kelley Lee, DPhil, Kathleen Liddell, DPhil, respiratory syndrome coronavirus 2
Marc Mendelson, PhD, Gorik Ooms, PhD, James Orbinski, MD, MSc, MA,
Laura J. V. Piddock, PhD, John-Arne Røttingen, MD, PhD, Julian Savulescu, PhD, (SARS-CoV-2) and its variants that cause
Andrew C. Singer, PhD, A. M. Viens, PhD, Clare Wenham, PhD, Mary E. COVID-19 has sparked new discussions
Wiktorowicz, PhD, MSc, Shehla Zaidi, MD, PhD, and Steven J. Hoffman, JD, PhD, LLD on the need for an international pan-
demic treaty,2 presenting a unique
ABOUT THE AUTHORS
opportunity to reflect on AMR as one
Isaac Weldon, Susan Rogers Van Katwyk, A. M. Viens, and Steven J. Hoffman are with the
pathway through which new cross-
Global Strategy Lab, York University, Toronto, Ontario, Canada. Gian Luca Burci is with
AJPH
the Graduate Institute of International and Development Studies, Geneva, Switzerland. border global health threats emerge.
Thana C. de Campos is with the School of Government, Pontificia Universidad Catolica de Similar to zoonoses such as COVID-19,
April 2022, Vol 112, No. 4
Chile, Santiago, Chile. Mark Eccleston-Turner is with the Department of Global Health
AMR can lead to untreatable infectious
and Social Medicine, King’s College London, United Kingdom. Helen R. Fryer is with the
Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield diseases in humans with the potential
Department of Medicine, University of Oxford, Oxford, United Kingdom. Alberto Giubilini to become deadly pandemics. AMR
and Julian Savulescu are with the Oxford Martin School and the Uehiro Centre for Practi- diminishes the global common pool of
cal Ethics, University of Oxford. Thomas Hale is with the Blavatnik School of Government,
antimicrobial effectiveness—a nonex-
University of Oxford. Mark Harrison is with the Faculty of History and Oxford Martin
School, University of Oxford. Stephanie Johnson is with the Wellcome Centre for Ethics cludable but rivalrous resource—
and Humanities and Ethox Centre, University of Oxford. Claas Kirchhelle is with the meaning that maintaining the viability
School of History, University College Dublin, Dublin, Ireland. Kelley Lee is with the Faculty
of antimicrobial therapy is a global
of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada. Kathleen
Liddell is with the Centre for Law, Medicine and Life Sciences, Faculty of Law, University of common-pool resource challenge.3
Cambridge, Cambridge, United Kingdom. Marc Mendelson is with the Division of Infec- Overcoming this challenge will require
tious Diseases & HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape global mechanisms to coordinate inter-
Town, South Africa. Gorik Ooms is with the Department of Public Health and Primary
ests and investments, limit free riding,
Care, Ghent University, Ghent, Belgium. James Orbinski and Mary E. Wiktorowicz are with
the Dahdaleh Institute for Global Health Research, York University. Laura J. V. Piddock is and steer cooperation toward preserv-
with the Global Antibiotic Research and Development Partnership, Geneva, Switzerland. ing the common pool. This aspect of
John-Arne Røttingen is with the Ministry of Foreign Affairs, Oslo, Norway. Andrew C. Singer
AMR enables us to draw lessons from
is with the UK Centre for Ecology & Hydrology, Wallingford, United Kingdom. Clare Wen-
ham is with the Department of Health Policy, London School of Economics and Political other common-pool resource chal-
Science, London. Shehla Zaidi is with the Department of Community Health Sciences, Aga lenges, such as climate change, in
Khan University, Karachi, Pakistan. building collective action to target the
pathways by which AMR may emerge,
A
ntimicrobial resistance (AMR) is across sectors and the ability of maximize the antimicrobial commons
among the most urgent global microbes to transfer among people, for everyone’s benefit, and avoid fur-
health challenges of our time. AMR can animals, food, and environments; ther descending into this tragedy-of-
develop with each use of an antimicro- spread across borders through global the-commons scenario.
bial, regardless of the setting. The trade and travel; and bring entire Building global collective action while
ongoing use of the same antimicrobials economies to a halt means that every accommodating varying national
Editorial Weldon et al. 553OPINIONS, IDEAS, & PRACTICE
circumstances is a monumental but, in choice as the dominant strategies to Paris Agreement’s annual Conference
our view, achievable task. The 2015 reduce global antimicrobial use.5,6 of the Parties to the United Nations
Paris Agreement under the United These strategies, which are reminiscent Framework Convention on Climate
Nations Framework Convention on Cli- of climate change mitigation strategies Change could be highly effective in
mate Change, for example, successfully that offload the responsibility for action shaping consensus and action over a
mobilized substantial collective action from governments to individuals, are short time horizon.8 A high-profile
to protect a shared global common- now acknowledged as insufficient. Anti- AMR forum composed of countries
pool resource similar enough to antimi- microbials have become such widely and nongovernmental organizations
crobial effectiveness that it can provide used tools that they are effectively would ensure ongoing and inclusive
lessons for advancing global action in invisible infrastructure underpinning dialogue to build a culture of account-
this area. While countries struggle to our health and food systems and paper ability, trust, and good faith among
meet their specific climate targets, the over shortcomings in basic hygiene, relevant actors. Crafting an inclusive
6
Paris Agreement has stimulated global equality, and labor systems. Individu- process will be essential for shaping
cooperation by engaging countries in als are therefore ill-placed to address equitable goals and actions, especially
an ongoing effort to mitigate green- AMR through more informed decision- because attempting to govern AMR
house gas emissions and adapt to the making. Instead, addressing AMR globally requires confronting questions
impacts of climate change. AMR lacks requires a commitment to social and about universal representations of the
an equivalent global vehicle for building economic transformation similar to the global public and its objectives.9,10
cooperation and would benefit from a one in the Paris Agreement’s call to Striking this forum, therefore, repre-
April 2022, Vol 112, No. 4
Paris Agreement–style coordinating action. sents an important first step to
structure. The Paris Agreement offers Third, escalating commitments ensure that future initiatives proceed
6 key lessons relevant to managing the through national AMR action plans, fairly.
global antimicrobial commons (Table 1). which outline each country’s AMR goals Fifth, like the Intergovernmental
and planned actions, will likely increase Panel on Climate Change guiding the
6 KEY LESSONS FOR AMR the effectiveness of global AMR efforts. Paris Agreement, ongoing AMR action
AJPH
Ongoing international monitoring of would be best informed by a regular
First, AMR needs a unifying global tar- national AMR action plans by the World and independent stock-taking to evalu-
get to mobilize political attention and Health Organization provides a key ate existing measures and advise on
benchmark global progress. For the starting point, but more extensive and evidence-informed adjustments.11,12
Paris Agreement, the world united ambitious global legal commitment This endeavor must (1) recognize that
behind the politically memorable, albeit mechanisms are imperative.7 In their different ways of knowing constitute
scientifically ambiguous goal of keeping nationally determined contributions the global knowledge base, (2) ensure
global average temperatures below under the Paris Agreement, countries that using evidence to inform adjust-
1.5 C above preindustrial levels or at are legally required to specify their ments that work does not detract from
least well below 2 C.4 For AMR, the level of ambition, regularly monitor the inherently political questions of
world still needs to develop, agree to, progress to that goal, and ratchet up works for what purpose and for whose
and unite behind a quantifiable goal their commitments every five years. benefit, and (3) come with a commit-
that resonates with nonexperts. Escalating national commitments over ment to equitable evidence generation
Second, effectively mitigating the time makes it easier for countries to and prioritization. Striking a panel to
threat posed by AMR requires a commit to action early, shape future assess the global knowledge base on
recognition of how embedded social policy directions, and signal their will- these terms will ensure that global,
structures and incentives drive antimi- ingness to cooperate. Although not regional, and national goals and poli-
crobial use across sectors. AMR efforts perfect, this model could increase the cies are continually informed by the
over many decades have largely level of ambition in current AMR best available evidence and are in line
focused on the behavior of individual commitments. with leading practices.12
health care providers and patients, Fourth, a permanent multistake- Finally, an enduring international
emphasizing education and personal holder forum on AMR similar to the legal agreement could institutionalize
554 Editorial Weldon et al.OPINIONS, IDEAS, & PRACTICE
TABLE 1— Comparing the Paris Climate Agreement With Existing Global AMR Efforts
Essential Elements Paris Climate Agreement Current Global AMR Efforts
1. Collective global goal Keep global temperature rise below 1.5 C above No consensus on what a collective global goal
preindustrial levels or at least well below 2 C could look like
2. A focus on social and economic Implementation of the Paris Agreement requires AMR discourse has historically emphasized
transformation social and economic transformation to individual behavior instead of social and
decarbonize national economies. economic transformation.
3. Nationally determined contributions pledged, All parties must communicate their nationally All WHO member states committed to having
reviewed, and ratcheted every 5 years determined contributions every 5 years and, national action plans for AMR. Even though
during revisions, aim for maximally ambitious this commitment is not legally binding, more
goals. Nationally determined contributions than 100 countries have published plans, and
are reviewed to ensure the distribution of many are under development. However,
responsibilities is fair and that countries are there are no specified review, intensification,
ambitious in their goals. All parties must or accountability mechanisms, and little
regularly provide information on activities financial, technical, and infrastructural
and outcomes using methods that are support is provided for achieving necessary
articulated by the Intergovernmental Panel policies. WHO, FAO, and OIE conduct self-
on Climate Change. assessment surveys on national AMR
activities, but there is no regular reporting
or standard methodology for reporting
outcomes.
4. Annual multistakeholder forum The annual Conference of the Parties to the AMR is normally discussed every 3 years at
UNFCCC serves as a multistakeholder the World Health Assembly, but there is
meeting place for advancing the Paris no formal or regular meeting focused
Agreement. on AMR and no permanent forum for
AJPH
multistakeholder discussions on AMR across
sectors.
April 2022, Vol 112, No. 4
5. Global scientific stock taking every 5 years Requirement to assess the best available No relevant comparison
science every 5 years; this stock-taking
exercise will help ensure that the Paris
Agreement’s ongoing efforts are in line with
scientific best practices.
6. International legal framework The Paris Agreement is a legally binding No international legal framework, although the
instrument of the UNFCCC. The UNFCCC constituting instruments of the WHO, FAO,
provides a broader legal framework for the OIE, or UN could serve as the broader legal
Paris Agreement. framework for a legally binding AMR
agreement
Note. AMR 5 antimicrobial resistance; FAO 5 Food and Agriculture Organization of the United Nations; OIE 5 World Organization for Animal Health;
UN 5 United Nations; UNFCCC 5 United Nations Framework Convention on Climate Change; WHO 5 World Health Organization.
Source. Rogers Van Katwyk et al.15
these actions with a long-term vision and link strategies across sectors, human health, animal, agricultural, and
and generate progress on AMR by countries, and time. 13
environmental sectors through a “One
charting a clear path forward, distribut- Whether through a standalone Health” approach to maximize the
ing responsibilities, and creating a sus- agreement or within a new pandemic global antimicrobial commons for
tainable system that makes countries treaty, an international agreement on everyone’s benefit and simultaneously
active participants throughout the pro- AMR could align incentives that switch improve infection prevention measures
cess. Treaties are appropriate for cer- the focus of AMR efforts toward pre- while promoting access, conservation,
tain kinds of challenges only—hence, vention and preparedness and coordi- and innovation for antimicrobials, alter-
they are rare in global health. However, nate investments to generate social native therapies, and diagnostic tech-
the escalating, transnational, and and economic transformation, espe- nologies.8 Coordinating a One Health
enduring AMR crisis means a strong cially because countries are unlikely to approach that appropriately engages
international legal framework is undertake these initiatives on their ministries of health, environment, agri-
required to hold actors accountable own. Such an agreement must unite culture, development, and finance
Editorial Weldon et al. 555OPINIONS, IDEAS, & PRACTICE
requires new legal mechanisms beyond antimicrobials. Without swift collective CONFLICTS OF INTEREST
those available through the World action now, though, AMR may undo S. J. Hoffman is Scientific Director of the CIHR’s
Institute of Population and Public Health and is
Health Organization, the Food and Agri- one of humanity’s greatest discoveries. CIHR’s Scientific Lead for Global Health. The views
culture Organization of the United This outcome would make AMR the expressed in this article are those of the authors
and do not necessarily reflect those of the Cana-
Nations, the World Organization for epitome of the global tragedy of the dian Institutes of Health Research (CIHR) or the
Animal Health, and the United Nations commons. To avoid such a catastrophe, Government of Canada. The other authors have
no conflicts of interest to disclose.
Environment Program, which are lim- world leaders must take ambitious
ited to the area-specific mandates of action—similar to the steps they took
each institution. REFERENCES
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