Being asked to coordinate a paper for the Journal of Law and Medical 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?
AMR is a huge disease issue. It’s been called the ‘silent pandemic’ since it currently causes substantial harm around the world and the scope of the problem is only getting worse. While peoples’ first thoughts about pandemic risk almost invariably jump to new viruses (which are absolutely important), the ongoing pandemic of AMR is killing huge numbers of people, affecting 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 that we have. If we don’t act aggressively, it’s going to get much worse.
The edition has lots of great information about why AMR needs to be in the pandemic instrument, governance issues related to that, what an instrument might achieve and what barriers might be present. If you’re interested in this area, I’d recommend checking out those articles.
I’ll comment here on the article that we wrote about animals. We were asked to write about how restriction of antimicrobial use (AMU) in animals and designation of antimicrobials for human use could be built into an instrument. However, we took a bit of a different tack. Part was 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.
It may sound simple….just use fewer antibiotics.
Yes, that’s part of the story but 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, may not help at all or may cause unintended negative consequences. We’ve seen all those outcomes in the past.
The short answer….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. Part of that is because of the complexity of the issue. Part of it is because of big data gaps. Part is because of a lack of understanding of key components.
I don’t want to take the lazy way out and just say ‘read the paper if you want more details’ but it’s actually not a bad recommendation if you want to understand the area. There’s more complexity than I can get across in a blog post.
However, here are a few points.
“Antimicrobial use” encompasses a wide range of uses, including treatment, metaphylaxis, prevention and, in some countries still, growth promotion. The issues differ between those.
Even within those categories, there can be lots of variation and lots of 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 higher 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 it’s unnecessary, done based on fear or habit vs evidence, or used in lieu of good management practices. We want to curtail those.
Ideally, we’d have all antibiotic use in animals driven directly by a vet. That works in areas where there is good access to veterinary care. It doesn’t work everywhere, at least 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 vet (or allied health professional). “Stop over the counter access to antimicrobials” makes sense in many places, but in some, it would compromise animal health and welfare. It’s even a challenge in some parts of Canada that are underserviced.
There are many similar things that sound simple, but get much more complex when you delve into them. Failure to understand that complexity dooms approaches to address this issue.
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 get our way out of this problem with a treaty, since there’s no single thing that can fix the scourge of AMR. However, the way we’ll address the problem will be 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.
If you’ve managed to make it this far through this post, maybe that’s a good indicator you’d be interested in reading the article or full edition. Enjoy.