The complexities of AMR!

As a Pharmacist I must say that antimicrobial resistance (AMR) keeps me awake at night. The World Health Organization (WHO) has declared that AMR is one of the top ten global public health threats facing humanity (https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance). By 2050, the United Nations (UN) estimates that up to 10 million deaths could be caused by superbugs and association forms of antimicrobial resistance, matching the annual global death toll of cancer (https://www.unep.org/resources/superbugs/environmental-action). What makes it scary is that regular procedures such as tooth removals could potentially become deadly if our antibiotics stop working. However, the question is, despite this warning and the looming threat, are we having enough action around this? And if not why?

Recently the World Antimicrobial Awareness week was rebranded as the World AMR Awareness Week as announced by the Quadripartite that includes the Food and Agriculture Organization of the United Nations (FAO), the United Nations Environment Programme (UNEP), WHO and the World Organization for Animal Health. While this is a great move towards creating awareness against AMR once again is it enough to talk about this for one week in the year?

Personally, I have always believed that AMR is something we need to talk about every day. The challenge of AMR is so complex that unless we make it a regular topic of discussion within communities and households there is very little that we will be able to do against it. Some important points to remember when it comes to AMR that highlight its complexity:

-???????AMR is a “money” issue. From Doctors pushing certain medicines to meet marketing targets (and receiving the related incentives), to Pharmacists providing antibiotics without prescriptions so that they “don’t lose a customer” to patients wanting to avoid paying at the health facilities for seeing a doctor or performing the necessary tests, there are enough incentives out there for different individuals in our communities to not care about AMR and continue with the behaviors that promote AMR.

-???????AMR is also a poverty issue. At the last mile where people don’t have the purchasing power, completing the dose of an antibiotic is not a priority. Whatever fixes the health challenges immediately will be done.

-???????AMR is a community behavior issue. I have seen many conversations about AMR happening between health professionals and in “scientific” rooms with images of petri dishes and complex data being presented. However, without these findings being translated into laymen language that can be understood by the communities there is little we will be able to do to change the behaviors that promote AMR.

-???????AMR is a convenience issue. Like the aspects around money there is also a lot of convenience that comes from avoiding long queues at health facilities and laboratories for testing. Both the health professionals and the patients want “easy ways out” and quick recovery. ?

-???????AMR is difficult to track. Especially in low- and middle-income countries where laboratory capacity may be limited, and medicine is practiced based on symptoms unless we are looking for AMR, we will never be able to find it. Deaths will get attributed to “bad luck”, “work of God” and complications without us realizing that the antibiotics were failing.

-???????AMR is a supply chain issue. In 2014 I was lucky enough to volunteer for a health camp in Iraq. A country where war and conflict has affected the supply chains of medicines drastically. During my experience there I realized that without the right supply of medicines, AMR becomes a distant issue with saving a life at the immediate moment becoming a priority. Would it be easier to save a life today by giving incomplete doses of antibiotics that provide some sort of relief or worry about a future where no antibiotics are working?

-???????AMR is a research, development, and domestic manufacturing issue. We need to think about developing new medicines and making them available and accessible especially at the last mile where we have availability related challenges.

-???????AMR is multi-sectoral. And that is why we have bodies like the Quadripartite bringing together organizations that work in relation to the environment, animal health and human health wanting to tackle AMR through a One Health Approach that looks at all these different sectors.

-???????AMR is a climate change issue. From the concerns around the melting icebergs releasing microbes from ancient times to the changing temperatures of the world making fungi more virulent, we have no idea how these changes in the environment and climate will affect the potency of our current antibiotics.

-???????AMR is everyone’s problem. Microbes and disease-causing pathogens don’t know borders. If there is anything we have learned from the COVID19 pandemic, it’s the fact that whatever happens in one country has the potential of spreading and affecting everyone else. We can’t fight AMR in one part of the world. We only win if everyone wins.

Perhaps it is these complexities that make AMR the kind of challenge that we want to deal with only periodically. Perhaps it is the “invisible/silent” nature of AMR as a health challenge that makes it fly under our radars. Perhaps it is the personal interests of individuals, health professionals and pharmaceutical companies that facilitate the negligence. However, this threat is here and is only growing.

Now, the aim of this article is not to promote hopelessness. We do have a lot of things that could work in our favor. We have the experiences of the COVID19 pandemic and the resultant push towards aspects such as domestic manufacturing of pharmaceuticals especially on the African continent. We have community level organizations in different countries trying their best to make noise around AMR (for example in Tanzania we have the likes of Tanzania Pharmaceutical Students Association (TAPSA), One Health Society and the Roll Back Antimicrobial Resistance (RBA) Initiative). We have technologies such as Artificial Intelligence that can help catalyze research and development in this space. What is needed is for us as health professionals to take this threat seriously and ensure regular and consistent action against it beyond just researches and reports. Together!