12 Feb 2016
Written by Dr Joseph Fitchett and Prof Rifat Atun
Dr Rifat Atun is Professor of Global Health Systems at Harvard University, and the Director of Global Health Systems Cluster at Harvard T.H. Chan School of Public Health. He is a member of the Longitude Committee.
Dr Joseph Fitchett is a Frank Knox Fellow in Public Health at Harvard University, with a concentration in infectious disease epidemiology and biosurveillance. He is co-founder of the Global Health Film initiative and RESIN: Research Investments in Global Health, both supported by the Bill & Melinda Gates Foundation.
The adoption of the Sustainable Development Goals (SDGs) heralds a new era for health and development. A total of 17 SDGs have now succeeded 8 Millennium Development Goals (MDGs), which have shaped and helped guide the international development agenda for the past 15 years. The breadth of the new goals widens the scope of sustainable development from 21 to 169 targets. This provides an opportunity for the SDGs to promote “health in all policies” and find synergies at the intersection of health and development.
Antimicrobial resistance (AMR) is, however, not mentioned once in the SDG targets. Estimated by the independent Review on Antimicrobial Resistance to reduce the global economy by $100 trillion, and the global population by between 11 and 444 million, strategies to address AMR are intrinsically connected and interrelated to several of the SDGs.
SDG goal 3 is linked directly to health. Arguably one of the most relevant Targets to AMR is 3.d, which seeks to: “Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks.” However, the scope is broad, non-specific, and requirements to control AMR extend far beyond the focus of the target.
Tuberculosis (TB) deserves a special mention. Target 3.3 aspires to “end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases” by 2030. The complexity of TB care and prevention is profoundly impaired by multidrug (MDR) and extensively drug resistant (XDR) strains of TB bacteria. With new cases now approaching half a million in 2013 alone, 17 of the 27 countries with the “highest burden” for MDR-TB are economically classified as low- and middle-income. Most concerning, however, is the lack of MDR-TB treatment, or individualised regimens, to prevent transmission. In 2013, 10 high burden MDR-TB countries treated less than 60% of diagnosed cases in 2013. A global, coordinated, multifaceted approach is required to address both the common factors promoting drug resistance across infections, and disease-specific issues.
In the United States alone, the Centers for Disease Control and Prevention (CDC) estimated direct costs of AMR to be $20 billion, with a further $35 billion in productivity costs. AMR must therefore remain on the agenda for economies to achieve sustainable growth for all.
Combined with SDG goal 13 to “Take urgent action to combat climate change and its impacts”, food security and climate change are greatly affected by antibiotic use in the human food system, agriculture, and aquaculture. In 2010, China and India alone accounted for more than 15,000 tonnes of antibiotic consumption by livestock – and without further regulation and concerted action this figure is set to rise to 40,000 tonnes in the next 15 years. Aligning the principles of “one health” and “planetary health” with the SDGs is therefore central to responding to the multiple dimensions driving AMR.
Finally, the role of innovation in research and development (R&D) is often a neglected, but essential, component in preventing a world without antibiotics. In December 2015, The Lancet Infectious Diseases published an assessment of public funding for antimicrobial resistance in Europe. Reviewing the landscape from 2007 to 2013, the authors found that €1.3 billion was invested in total, with misalignments in funding channels. Only €12.5 million was dedicated to R&D and the environment, and only €25.1 million to surveillance.
Without enhanced capacity and linkage between epidemiological and laboratory data, and truly global partnerships with low- and middle-income settings, AMR will threaten the achievement of the SDGs. HealthMap have launched a global, open surveillance system for AMR in an effort to work alongside their current surveillance technology. Support and commitment from all states will help realise the vision and scale of the project.
An innovative financing mechanism for antimicrobial resistance does not exist, such as the global initiative UNITAID which identifies and finances health solutions that show promise for HIV, TB and malaria. Perhaps now is the time to conceptualize how such a global initiative could integrate AMR.
The SDGs are ambitious and aspirational, and intentionally so. Despite their limitations, they offer a window of opportunity to shape health and development. Sustainable development and access to affordable and effective antibiotics are intrinsically interlinked, making decisive and coordinated action in the coming years clearly needed.
