On 21 September, 2016, policymakers, researchers, and non-governmental actors paid close attention to the High-level Meeting on Antimicrobial Resistance (AMR) at the United Nations General Assembly—only the fourth time in the UN’s history that a high-level meeting on health had been convened. AMR is an emerging public health crisis: it develops when bacteria are exposed to antibiotics and adapt. It encompasses medicines prescribed for viral, parasitic, and fungal diseases. AMR bacteria can spread through humans, animals, food (both retail and agricultural products), and travel. A World Bank report, published days before the UN meeting, estimated that the economic impact of drug-resistant infections would likely surpass the 2008 financial crisis, with particularly devastating effects for developing countries, that might see cumulative losses of nearly 5% of their GDP. 1 By 2050, healthcare costs are expected to balloon from $300 billion to more than $1 trillion annually by 2050, and global livestock production would decline by almost 7.5% each year. AMR has been called a “slow-motion tsunami,” as bacterial resistance snowballs amid a dry innovation pipeline. 2 The last time scientists discovered a new class of antibiotics was 1987, which is worrying as resistance to one agent invariably leads to an entire class. 3
All 193 member states eventually adopted the political declaration issued at the meeting’s conclusion. Many greeted the declaration with approval: Médecins Sans Frontières lauded it as an “important political step,” while the Centre for Strategic and International Studies called it a “significant achievement.” 4 This is surprising, as the declaration mirrors the World Health Organization’s (WHO) 2015 Global Action Plan on AMR. Its importance shrinks even further when contextualized historically. The WHO was already issuing warnings about the harms of AMR in the 1950s, and by the 1980s, scientists began coalescing around advocacy, launching the first known international scientific advisory board charged with addressing AMR. 5 More recently, significant momentum has been building on addressing AMR through global governance institutions, including the creation of new ones. The Global Health Security Agenda, an initiative launched in 2014 between countries, international organizations, and non-governmental bodies to collect country-level assessments on progress made in addressing infectious diseases. 6 Several states have taken lead into moving the agenda forward. The United States convened the White House Forum on Antibiotic Stewardship in 2015. 7 In 2014, the United Kingdom, together with the Wellcome Trust, commissioned an independent review on AMR. The findings were published in a lengthy report this year, with ten concrete recommendations for next steps. 8 These select examples demonstrate that the global community has already achieved a consensus; scientists, policymakers, and key global actors need to make use of the policy window afforded. The UN declaration merely rehashes what the international community has been well aware of the last half century. In short, the UN did not take the opportunity to offer a more robust response to this global health crisis.
What tools would allow us to make concrete progress on AMR? One underexplored mechanism is international law. The vast majority of global health challenges can be addressed through national institutions and actors. For a small subset, which include epidemics and AMR, an adequate response requires collective and coordinated international action. Any solution must be able to address the three facets of the AMR issue: access, conservation, and ongoing research innovation. Coordinating the three within each country is already a complicated task for most governments; it would be hard to see how countries would be able to coordinate with each other in a committed fashion. International law offers the clearest route forward for two reasons: First, AMR is a transnational health problem that does not respect sovereign borders; second, it is also a classic collective action problem, with coordination problems that only coercive legal tools can address. 9 Some global health policymakers and researchers have started proposing the contours of what an international treaty should look like. A successful treaty would span funding (for innovation, access, and surveillance), regulation (e.g. global standards for prescription, human-only classes), and surveillance. 10 More needs to be done, particularly in fleshing out how commitments can be monitored and enforced. 11