There is an urgent need to bring global governance to the effort to preserve the effectiveness of antibiotics. The issue of increasing antibiotic resistance, and the need to use antibiotics more wisely, has gained recognition at the highest political echelons, and there is evidence for antibiotic-conserving interventions that all countries could adopt to reverse the global threat.
This confluence of factors makes the possibility of negotiating a global treaty aiming to reduce misuse and overuse of antibiotics in humans and animals more viable than ever before. It is an opportunity that should be seized.
Antibiotics are a core tool of modern medicine, but are increasingly being rendered ineffective by the ability of bacteria to develop resistance. Drug-resistant infections are already estimated to kill at least 700,000 people a year, and could kill 10 million people a year by 2050 if left unchecked.[1]
The potential impact of antibiotic resistance also threatens development and the global economy: recent estimates warn that the economic damage from uncontrolled antimicrobial resistance could be comparable to that of the 2008 financial crisis.[2]
While bacteria have a natural ability to develop resistance, making some level of antibiotic resistance inevitable, persistent misuse and overuse of antibiotics in humans and animals have encouraged the pace at which resistance develops to accelerate. We now urgently need to reverse course.
In the last few years, international agencies have developed strategies and guidance that identify and recommend evidence-based interventions. However, a critical missing piece to the response is a global governance mechanism.
Antibiotics are used to treat infections not only in humans, but also in animals and plants. Resistance is therefore a complex problem that also affects food and the environment, and it transcends borders. It cannot be tackled successfully by a single country or international agency. It needs a coordinated, multisectoral response.
Current multilateral approaches, though extensive, are insufficient in key respects. The strategies, global action plans and recommendations developed recently by the ‘Tripartite’ of UN agencies leading the response at the global level[3] – the World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the World Organisation for Animal Health (OIE) – set out a comprehensive range of sound interventions for countries to write into their national action plans on antimicrobial resistance.
However, not all countries have the capacity to adopt all of the recommended interventions. To generate the scale of focused response needed and bring effective global governance and accountability to the effort, there is now a need to agree on a handful of priority measures that all countries can commit to and implement in unison.
A legally binding global treaty to curb the misuse and overuse of antibiotics is an attractive and viable option to consider in this respect. Given the magnitude and urgency of the threat, it may be the best instrument for maintaining and increasing political will, for helping countries zero in on the most feasible interventions and develop the legislation necessary to implement them, and for filling the global governance gap in antibiotic stewardship.
Such a treaty should specify a prioritized set of interventions, with target timelines and phased implementation. It should be flexible enough so that it can be amended to include more interventions and future innovations, as political will increases and as new, globally feasible tools become available. Such a treaty should also include a robust accountability mechanism, requiring regular tracking of progress in implementing the treaty’s provisions.
One of the first steps should be to embark on a process to identify which of the interventions proposed in the global action plans, strategies and guidance of WHO, FAO and the OIE would be priorities and feasible for all countries to implement. The Tripartite is the natural choice for this exercise, particularly given that these agencies have called for strengthened accountability and global governance.[4]
A determination would need to be made as to under which institution’s authority such a treaty should be negotiated. If the proposed provisions fall under the mandates of more than one international agency, it might make sense for the treaty to be negotiated under the UN.
The findings of the prioritization and feasibility exercise should then feed into the negotiation of the treaty, which should contain the interventions that all parties can agree to include and be bound to deliver. Some measures that could be given serious consideration include prohibiting doctors and veterinarians from selling antibiotics, banning the advertising of antibiotics, increasing the use of vaccines that prevent bacterial infections in animals and humans, phasing out the use of antibiotics for livestock growth promotion, and improving hygiene in the management of human and animal waste.
Negotiation and acceptance of a treaty to curb improper use of antibiotics would not be without significant challenges. There are a huge range of social, economic and cultural factors contributing to the misuse and overuse of antibiotics. Political commitment will be necessary for success, and a handful of countries would need to step up as champions of the idea.
Countries that have thus far championed the issue include the UK and many other industrialized nations. The more countries back the idea, the faster the process would move.
The role of civil society advocacy also cannot be underestimated. One of the keys to success of the first global health treaty negotiated under the auspices of WHO – the Framework Convention on Tobacco Control (FCTC) – was the push from non-governmental organizations and other civil society groups. WHO estimates that the prevalence of smoking has decreased globally from 24 per cent of the population aged 15 or older in 2005, when the treaty was signed, to 19 per cent in 2017.[5]
The FCTC, ratified by 181 of the 194 WHO member states, is a useful model in many ways. For instance, it is a flexible treaty that provides carefully selected evidence-based options that are feasible for all countries and obligates countries to regularly report progress in implementing its provisions.
However, a treaty to curtail antibiotic misuse and overuse would face an important challenge that did not apply to the FCTC: while the solution for tobacco control is to get as many people as possible to stop using tobacco, the solution for the control of antibiotic resistance is to stop the misuse or overuse of antibiotics, not all use.
It would be critical to ensure that interventions avoid impeding access to antibiotics for those who need it. While curtailing misuse and overuse is central to addressing the problem of antibiotic resistance, it is estimated that more people die from no access or delayed access to antibiotics than from antibiotic resistance.[6]
The balance between increasing appropriate access and reducing inappropriate use must be struck, which means that some of the interventions that would help reduce misuse and overuse – such as requiring a diagnostic confirmation before antibiotics are prescribed, or that access to antibiotics be allowed only with a doctor’s prescription – would not be feasible in some countries, so other provisions would need to be considered.
Despite the challenges, there is now enough political traction around the issue of antibiotic resistance to warrant serious consideration of the negotiation of a legally binding international instrument. The idea is garnering support from experts and advocates for the responsible use of antimicrobials.[7]
Governments are also paying more attention to the issue. At a UN General Assembly high-level meeting devoted to antimicrobial resistance in 2016, heads of state confirmed their commitment to taking a coordinated approach and pledged to develop national plans based on the WHO Global Action Plan on Antimicrobial Resistance, endorsed by health ministers at the World Health Assembly in 2015.
The UN secretary-general subsequently convened the Tripartite of WHO, FAO and the OIE in the form of an Ad-hoc Interagency Coordination Group (IACG) on Antimicrobial Resistance,[8] to provide guidance on what global actions were needed, and called on the agencies to finalize a proposed Global Framework for Development and Stewardship to Combat Antimicrobial Resistance.[9]
The final recommendation of the IACG’s report to the UN secretary-general, published in April 2019, opens up the possibility of using the ongoing process of developing the Framework as a starting point for discussion of ‘new binding or non-binding international instruments’.
As the negotiation of a global treaty is a lengthy process, and the threat of antibiotic resistance is urgent and growing every day, current efforts to coordinate the response at the global level must not stall. The need for a global governance and accountability mechanism and the potential for a treaty to deliver that, meanwhile, deserve serious consideration.
Professor David Heymann CBE, Head and Senior Fellow, Centre on Global Health Security and Emma Ross, Senior Consulting Fellow, Centre on Global Health Security.
Notes
[1] Interagency Coordination Group (IACG) on Antimicrobial Resistance (2019), ‘No Time to Wait: Securing the future from drug-resistant infections’, https://www.who.int/antimicrobial-resistance/interagency-coordination-group/final-report/en/ (accessed 11 May 2019).
[2] Ibid.
[3] WHO (2018), ‘FAO/OIE/WHO Collaboration (Tripartite)’, https://www.who.int/zoonoses/concept-note/en/ (accessed 11 May 2019).
[4] IACG (2019), ‘No Time to Wait’.
[5] WHO Framework Convention on Tobacco Control (2018), 2018 Global Progress Report on Implementation of the WHO Framework Convention on Tobacco Control, Geneva: WHO, https://www.who.int/fctc/reporting/WHO-FCTC-2018_global_progress_report.pdf (accessed 11 May 2019).
[6] Laxminarayan R., Matsoso P., Pant S., Bower C., Rottingen J. A., Klugman, K. and Davies, S. (2016), ‘Access to effective antimicrobials: a worldwide challenge’, Lancet, 387(10014): pp. 168–75, doi:10.1016/S0140-6736(15)00474-2 (accessed 11 May 2019).
[7] Padiyara, P., Inoue, H. and Sprenger, M. (2018), ‘Global Governance Mechanisms to Address Antimicrobial Resistance’, Infectious Diseases, 2018 (11), doi: 10.1177/1178633718767887, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5900814/ (accessed 11 May 2019).
[8] WHO (2019). ‘Ad-hoc Interagency Coordination Group on Antimicrobial Resistance’, http://www.who.int/antimicrobial-resistance/interagency-coordination-group/en/ (accessed 11 May 2019).
[9] WHO, FAO and OIE (2017), ‘Global Framework for Development & Stewardship to Combat Antimicrobial Resistance Draft Roadmap’, http://apps.who.int/medicinedocs/en/m/abstract/Js23198en/ (accessed 11 May 2019).
This essay was produced for the 2019 edition of Chatham House Expert Perspectives – our annual survey of risks and opportunities in global affairs – in which our researchers identify areas where the current sets of rules, institutions and mechanisms for peaceful international cooperation are falling short, and present ideas for reform and modernization.