Response to the Antimicrobial Resistance Crisis
Coupling One Health with Increased Environmental Representation and Glocalization in Response to the Antimicrobial Resistance Crisis
The discovery of antimicrobials revolutionized clinical and agricultural practices for its ability to kill infectious microbia. Paradoxically, its overuse has resulted in the development of antimicrobial resistance (AMR), whereby the microbia evolve to overcome the selection pressures set by antimicrobials. The rise of AMR is one of the most pressing and complex public health and environmental issues, challenging healthcare systems all over the globe. It has been suggested to lead to millions of preventable deaths and to hundreds of billions of dollars in economic costs annually (Anderson et al., 2019). AMR is a problem that transcends borders, with its grave risks impossible to avoid for any state without collective global action, necessitating effective global governance mechanisms. AMR’s rising threat is not a new issue, as drug resistant infections are estimated to cause 700,000 deaths annually around the world (WHO, 2019). Moreover, 5.7 million deaths have resulted from inaccessibility to antibiotics, making it a clear threat to the world’s sustainable development (Jasovský et. al., 2016). Human activity contributes to AMR through antibiotic and excessive antimicrobial use in the environment, healthcare systems, and agricultural business; thereby threatening food security, livelihoods, and international health (WHO, 2019). If not dealt with adequately, AMR could lead to rising costs and declining effectiveness of healthcare, disease treatments, and infection prevention methods. This could contribute to a decrease in annual global GDP by 3.8% in 2050 (Dadgostar, 2019).
Apart from being a global health problem, AMR is also a worldwide environmental concern due to its adverse impacts on the environment. The large deposition of pesticides, heavy metals, and antimicrobials daily into the environment from the pharmaceutical industry, livestock agriculture, aquaculture, hospital sewage, and urban activities pollute the water and air
(Andleeb et al., 2020). Further, the sludge obtained from sewage and used in recycled form for farming activities contain some specific antimicrobials and AMR microbia, which have adverse effects on the microbial and algal communities (Andleeb et al., 2020). Resistant microbial communities in soils have displayed an inhibited ability to denitrify, impairing the nitrogen cycle which is crucial to forest and ecosystem success (Costanzo et al., 2013). Additionally, the presence of antimicrobials in soils has been shown to decrease biomass and bacterial taxa diversity (Liang et al., 2017; Eckert et al., 2019), while its presence in aquatic systems has been shown to impair carbon cycling and productivity (Kraemer et al., 2019). These AMR communities have also been shown to impair reproductive systems and maturity of vertebrates and invertebrates (Kraemer et al., 2019), which could destroy both aquatic and terrestrial ecosystems, especially if keystone species are affected. Human consumption of animal produce infected with AMR could result in the colonization of natural gut microbiota by the antimicrobial community, which put the consumer at a high risk of opportunistic infections (Linton, 1986).
To address these AMR and health equity issues, the WHO developed the ‘One Health’ approach as the leading global methodology to counter these threats. It is a single, legally binding approach argued to be the “most effective way of achieving a global governance system that can bring about ambitious AMR goals” (Van Katwyk et al., 2020). It has allowed for increased coordination, communication, and collaboration across different sectors and governments. Standardisation, shared responsibilities, and increased global health security have been the results of this approach (Sinclair, 2019). Although One Health has addressed some of the issues arisen due to AMR, it has ultimately fallen short in other aspects as well. Thus, this paper will argue that, in mitigating the rise of antimicrobial resistance, one must utilize a multidisciplinary approach wherein the One Health approach is combined with initiatives to
increase environmental representation in One Health practices, and for facets of glocalization to be included in global governance mechanisms to ensure low- and middle-income countries (LMIC’s) are protected from the dangers of AMR as well. It will first explain the merits of One Health along with its shortcomings, before illustrating the pressing need for more environmental specialists within One Health. This paper will then explain the concept of glocalization and how it can be adapted to improve the current One Health model.
One Health Approach
Instituted by the WHO-FAO-OIE tripartite, the One Health approach provides a transdisciplinary perspective when seeking to solve problems, considering the interconnectedness between humans, animals, and the environment. This multisectoral approach is ideal for AMR because antimicrobials are used in animals, humans, and the environment, and all these groups interact. This animal-human bond will beneficially impact the health of both humans and animals, along with the greater environment.
We would not have discovered certain strains of resistance if we had not considered that the environment would be a vector for its spread. By having a team of environmentalists, we were able to trace the source of resistance development, and a team of biochemists allowed for sequencing of resistant strains to pinpoint its origins and mode of development. However, a fuller understanding of the ecological and evolutionary processes leading to the clinical appearance of resistance and knowledge of environmental dispersal barriers are lacking severely (Bengtsson-Palme, Kristiansson, Larsson, 2018). Thus, the One Health approach seeks to mitigate AMR through global governance processes, rather than through solely positivist means.
Incorporating a One Health approach into public health policy is expected to increase productivity and reduce costs by reducing the overlap between public, animal, and ecosystem health sectors. Based on these anticipated benefits, One Health initiatives have been established in many different intergovernmental organizations and institutions. These initiatives promote “integrated research, surveillance, and control programs and policy frameworks'' (Baum et al., 2017). The authors further explain that One Health curricula have also been incorporated into several public health and veterinary degree programs, showcasing its increased popularity. The World Bank reported significant costs of diseases occurring at the human-animal-environment platform, necessitating a One Health approach. They further explained that there is a high global return value in the investment of prevention strategies through “strengthening veterinary and human health capacity” (Smith et al., 2019).
One Health, on an individual country level, will seek to improve administrative structures, build the capacity of the veterinary profession, organize inter-agency relationships, mainstream issues of climate and environment change, and stress the importance of demographic analysis in infection control and prevention (Videla & Urzua, 2014). The One Health initiative further recognizes not only the interconnectedness between animals, humans, and the environment, but also the importance of building bridges between the various different physicians, veterinarians, environmental scientists, and public health professionals. This multi-sectoral approach facilitates mutual collaborations, allowing for “veterinarians and physicians [to] accomplish so much more to advance the health of humans and animals” (Food and Drug Administration, 2020). However, it is argued that despite these initiatives, there has been miniscule focus on measuring the cost-savings, efficacy, or reduced duplication of effort.
within One Health programs. Moreover, a lack of standardized One Health metrics showcases limited objective evidence on the potential anticipated benefits of these programs. Furthermore, many of the nations implementing One Health initiatives lack both the human and financial ability to implement stewardship programmes. Nations do not have the same level of “resource access, technical capacity, human resources, research capacity, and agenda-setting privileges,” which leads to many countries not being able to “set, formulate, legitimate, or adopt practices” due to resource constraints (WHO, 2019). To address this gap, the WHO developed a Global Antimicrobial Resistance Surveillance System (GLASS); however, they are unable to harmonize surveillance efforts due to differing metrics and methodologies to measure AMR worldwide, and due to poor enrollment (Rogers Van Katwyk, Giubilini, et al., 2020). The One Health approach further suffers from countries’ lack of ability to measure its impact and document cost-savings (Sinclair, 2019). Thus, it is contested that in order to maximise the benefits of One Health in a globally equitable fashion, there must be more environmental representation along with glocalization implemented into the framework.
Between 30% and 90% of used antimicrobials are deposited in microbial waste lagoons through animal urine and manure, where they are then able to develop AMR (Costanzo et al., 2005; Sarmah et al., 2016). These AMR residues may then be run off into rivers, be transmitted through the air, enter new farmlands, or be carried by humans/animals as vectors (Zhu et al., 2013; Liang et al., 2017). Therefore, interventions that target the environment can control the number of resistant bacteria that go into people’s surroundings.
Despite the clear importance of the dynamic role the environment contributes to the spread of AMR, there has been a documented lack of representation of environmental effects on One Health teams around the world tackling AMR. Iossa and White (2018) analyzed 18 national action plans in response to AMR to gain insight on how much of the environment is integrated within the One health approach. It was found that 12 of the 18 plans stated a One Health approach in their strategic objectives, but only so for human and animal health surveillance, with acknowledgement that the environment is intended to receive more integration in the future. Further, through a meta analysis of the composition of One Health systems targeted at AMR mitigation, it was shown that national action plan teams predominantly consist of human-animal health representatives, with environmental specialists being largely neglected (Khan et al., 2018). Such observations could be explained by the fact that mechanisms of resistance spread are better understood in human-animal systems, which has resulted in much research and work on surveillance methods to address those sectors. Additionally, the One Health approach was initially developed through the need to address disease outbreaks, and was thus mainly pursued by physicians and veterinarians, leading to an inherent bias towards addressing the human-animal sectors’ role in AMR.
The environment negatively impacts the spread of AMR, and AMR spread likewise destroys the environment. Thus, there is a desperate need for One Health to ensure a more complete representation and focus on the environment's role in AMR spread with a stringent effort in developing environment surveillance frameworks for resistance, designing various methods to treat waste, and developing healthy waste disposal methods. Such policies could also delve into developing effluent standards from industries and farms regarding antimicrobial residue limits or bacterial load.
In this paper, the usage of the term, “glocalization,” refers to the process of describing a product or service that is developed and distributed globally, but also adjusted to accommodate the user in their respective local market. A linguistic hybrid of globalization and localization, this theory can be utilized to address many of the shortcomings of the One Health initiative.
While there have been many prominent calls for binding global commitments and strengthened global institutions, there has been significantly less attention paid to the tensions between global and local solutions in mitigating antimicrobial resistance. These tensions are especially prominent in the stewardship of AMR, such as in formulating policies and strategies to alleviate AMR. One criticism of One Health, as Olivier Rubin (2019) explains, is its consistent comparisons of AMR to climate change. While there are many similarities, one key lesson from the fight against climate change is that “binding commitments are not necessarily effective” – such as legally binding commitments in the recent Paris Agreement being abandoned (Rubin, 2019). Such failures could be explained by the tragedy of the commons, whereby the overproduction/overuse of antimicrobials for individual gain has led to resistance development, rendering antimicrobials useless in both its efficacy and economic value. Thus, instead of addressing AMR through transnational global commitments that have not worked in the past in other contexts, the global challenge of AMR requires solutions defining boundaries for antimicrobial use at the local level. Henceforth, it is contested that One Health must implement the analytical lens of glocalization within its frameworks.
Each nation, society, and community have their own solutions that are tailored to their specific problems. AMR, unlike climate change and universal emissions targets, does not have one universal framework that can be utilized in all nations. Rather, in some countries, the best AMR strategy could be to provide incentivization for the reduction of the use of antibiotics for physicians, while in other nations, access to clean drinking water or effective diagnostics are greater priorities. Analyzing AMR stewardship through the prism of glocalization places an “emphasis on tensions between the universal (global) and the particular (local)” (Rubin, 2019). It is argued that global issues must be faced through the reconciliation of the global and the local.
To implement ‘glocal’ governance in One Health initiatives, one possible method would be policy diffusion, where countries or institutions set the best practices that spread across states and then adapted to local contexts. Moreover, polycentric governance is another effective glocal governance strategy. Instead of being within a hierarchical structure, poorly situated to address
issues affected by regional and local dynamics, polycentric governance builds on a “network of multiple and transboundary governing authorities capable of drawing on local knowledge, mutual monitoring, and peer learning” (Rubin, 2019). This ensures policy sustainability and efficacy, as the initiative capacity originates from the same bottom-up network. Rubin further mentions a last strategy, Problem-Driven Iterative Adaptation (PDIA), which should be implemented within One Health approaches due to its priority in solving problems in specific local contexts rather than transplanting “best practice” solutions (2019). This is a gradual problem-driven strategy, creating problem-driven policies that can benefit from greater specificity with regards to “design, implementation, monitoring, and surveillance” than is possible under universal treaties or guidelines. Thus, to ensure all nations are equipped to mitigate AMR, the glocalization perspective must be implemented within One Health initiatives.
The global challenge of AMR is one of the biggest public health and environmental challenges in our time, and thus requires serious measures to be implemented to mitigate its threat. While initiatives like One Health have arisen, it is contested that they have been insufficient in providing representation of environmental specialists, and inadequately providing universal, globalized solutions when local, glocalized solutions are urgently needed. To ensure a more adequate representation of the environment in the One Health approach, national plan teams must prioritize gathering environmental specialists and restructuring policies to incorporate more of an environmental perspective in the spread of AMR. Further, global systems must be coupled with local policy to provide a glocalized solution to generate policies that are more practical upon implementation. If such changes are made to the current One Health approach, we would come one step closer to finally solving the AMR crisis.