The year 2015 will leave an indelible mark on global health and many global health stakeholders alike. There was, obviously, the devastating Ebola epidemic, which sent shock waves around the world, but on the bright side, the many lessons learned (at least in panel reports) perhaps also laid the foundation for the unprecedented commitment to tackle Antimicrobial Resistance (AMR) witnessed in 2015. For the battle against AMR, the Ebola outbreak was a blessing in disguise, of sorts. As a wake-up call, it clearly gave a boost to the global health security agenda.
But first, what is AMR and what can be done about it? Microbes have the ability to adapt irrespective of changes in their ecology, reminiscent of the adage “survival of the fittest”. The adaptation relies on exposure of the microbe to therapeutic agents, inter-and intra-microbe species exchange of resistance genes and exposure of humans to these microbes. Hence, efforts to contain AMR as a global health threat target either one or all of these three critical events. Neither the inevitability of development of resistance among microbes, nor the interventions to curtail AMR are new but what boggles my mind is why it took decades for the world to agree on and mount an adequate response against AMR development (or at least start with it). In their 2014 paper, Laura J. Shallcross and Sally C. Davies chronicle a total of ten (!) World Health Assembly resolutions on AMR since 1998 that went unheeded. In fact it’s rumored that the WHO Global Strategy for Containment of Antimicrobial Resistance was scheduled to be released on September 11th 2001, when all hell broke loose at the World Trade Center and AMR was overtaken by terrorism as the leading global security threat.
The world hasn’t made much progress in the so called “War on Terror” since then, but on AMR, during the first decade of the 2000s, public health departments in Sweden and some G7 nations continued to analyze data from robust and comprehensive health information systems linking antimicrobial use, laboratory and clinical information. Reports demonstrated the escalation of AMR and potential ramifications for routine hospital and treatment procedures if AMR was left unchecked. For many commentators, we face a real possibility of a world without antibiotics in less than 20 years, and hence a return to the “dark age” of medicine.
The O’Neill review report, “Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations” (Dec 2014) was, together with the raging Ebola crisis, perhaps the tipping point. The review had been commissioned by the UK prime minister in July 2014, and the O’Neill review papers managed to take the worrying message on AMR to epidemiologists, capitalists, philantrocapitalists, sociologists and the Davos elite, by providing estimates of the enormous impact of unchecked AMR on the world’s mortality, GDP and economy. O’Neill’s key message: “Drug-resistant infections will cause 10 million deaths a year and cost up to $100 trillion a year by 2050”. Clearly, the kind of message Davos men and women can relate to (especially the second part).
The African picture
O’Neill’s first review paper also showed that AMR would have a different impact in different parts of the world. Over 40% of the expected mortality impact (by 2050) would happen in Africa (with more than 4 million expected AMR related deaths a year in Africa only). Suffice to say, if Africa is not to be left behind again, African countries will need to cover a lot more ground to reverse the trend in the race against the smart superbugs.
What is the picture so far on the continent?
With the meager data available on Africa’s AMR situation, resistance has already been reported for organisms that cause malaria, AIDS, Tuberculosis, cholera, dysentery, typhoid, gonorrhea and pneumonia.
AMR situational analyses by the Global Antibiotic Resistance Partnership (GARP) project in Uganda, Kenya, Tanzania, South Africa and Mozambique have found all five countries ill prepared to intervene to curtail AMR. The analyses have identified weaknesses in all known determinants of emergence of AMR. In addition to a lack of policy and frameworks to address AMR, many countries have weak medicines regulatory capacity, inadequate laboratory infrastructure for AMR testing and reporting and lack of reagents and consumables to reliably support AMR surveillance. In some countries, only AIDS, TB and malaria resistance is considered significant – there might be a link with donor priorities there, although the O’Neill report also indicated that “countries that already have high malaria, HIV or TB rates are likely to particularly suffer as resistance to current treatments increases”.
The African Union has supported collaboration between and coordination of public health laboratories through the African Public Health Laboratories Network (APHLN) with a view to addressing the Global Health Security Agenda on AMR.
On the policy front, a ReAct Africa Node (RAN) was established in 2014, following a meeting of African champions from 10 countries to discuss strategies and innovations to tackle AMR. ReACT fosters debate and collaboration among diverse stakeholders in countries and globally for action against AMR. It uses an innovative holistic approach including empowerment, engaging with and extending networks, translation of evidence into actionable policy for key stakeholders, …. It also has a web-based repository designed to function as a one-stop center for novices and experts on AMR. More recently, ReACT Europe supported the policy process in Ghana culminating in the launch of the country’s AMR Policy.
The adoption of the Global Action plan on AMR at the 68th World Health Assembly earlier this year will mark a point in history when the tide turned against AMR. In preparation for this action plan, many African countries are starting near bottom on most if not all of the actionable items. Whereas AMR seems to suggest restriction of antibiotics in many parts of the world, for low and middle income countries the key tension is about guaranteeing access to essential antimicrobial products without fostering excessive use. In addition to a ‘One Health’ approach, a proper AMR response also provides just another imperative to strengthen health systems with mechanisms such as health insurance, de-linking revenue from sale of antibiotics to foster access to quality assured antimicrobials, diagnostics, preventive measures, and evidence-based management protocols for all in need. Approaches will need to be context-specific as some African countries have pluralistic health systems with government run health centres, and non-state players such as mission hospitals, community, private drug outlets, …. Using proven interventions such as WHO/UNICEF’s integrated community case management for childhood illness to address the lack of access to life saving diagnostics and medicines in remote areas is only one suggestion for the African battle against AMR.
African countries could use South Africa’s antimicrobial resistance strategy framework as a benchmark. It focuses on three pillars (AMR surveillance, antimicrobial stewardship and infection prevention, control and vaccination) and embeds these in an already existing legal, regulatory and operational framework. It also recognizes that progress will be made against AMR only if these pillars are underpinned by strengthening health systems, educating the workforce and public, strong and functional high level governance as well as a rich and comprehensive legislative regime. It also notes the importance of operationalizing the strategy from setting national core standards to incorporating AMR into job descriptions, performance appraisals and continuing educational activities. Implementation should seek to build on the legal and regulatory framework present in most African countries and thus focus on enforcing the provisions better.
The easy part will be identifying key people from animal husbandry, agriculture and human medicines to form National Taskforces on AMR. More energy will need to be spent on translating strategic actions into downstream AMR activities targeting each of the five objectives of the Global AMR Action Plan. If I were in charge, I’d start by strengthening the knowledge and evidence base though research and surveillance. Given that nations will be in the AMR fight for the long haul, creating and sustaining human and animal health databases for clinical information, antimicrobial use, laboratory tests, resistance development and spread, AMR surveillance, diffusion of diagnostics and other innovations against AMR could not be more urgent. Choice of future interventions and evaluation of progress on the other AMR objectives will depend on access to timely, relevant and good quality data. Even the pharma industry in the business of developing newer antibiotics will ask: how soon do you need the new antibiotic, for how many people and where? African governments should prove their sovereignty by investing in the clinical and health information databases of our time and contribute to saving the world at least USD 100 trillion by 2050. As well as millions of lives.
In short, African countries have their AMR response work cut out !