Over the last century, humanity has made tremendous progress in the fight against infectious diseases. As a result, the majority of the world’s population now enjoys a significantly longer and better quality of life. In fact, the strides made in public health are recognised as a key driver of economic growth worldwide, improving productivity and increasing life expectancy.
Remarkable advances in the life sciences and innovations in healthcare have enriched our ability to overcome an increasing variety of public health challenges. Yet, despite these new capabilities, humanity still remains ill-equipped to combat emerging infectious diseases. Ironically, human progress is partially responsible for our increasing vulnerability to novel pathogens. Like other threats to humanity, we have the ability to do something about it, if we act in tandem.
The public health community should be proud of its accomplishments, but there is danger in complacency. We simply cannot afford to assume that drugs we use today to treat infections will always work, or that they are a panacea for future infectious diseases. In fact, as Figure 1 illustrates, the armamentarium of drugs that are presently used to treat common infections have become less effective over time as the pathogens naturally develop resistance. Those people unfortunate enough to experience a drug-resistant infection are typically left with few treatment options. These typically involve costly second and third line therapies, and only if those resources are available to the patient.
Figure 1 - Timeline of antibiotic deployment and the evolution of antibiotic resistance
Source: Timeline of antibiotic deployment and the evolution of antibiotic resistance. Clatworthy A.E., et al. Targeting virulence: a new paradigm for antimicrobial therapy. Nature Chemical Biology. 3,541-548(2007)
To truly capture the extent of the drug resistance issue, it is important to first understand that antibiotic resistance applies only to the therapeutics used to treat bacterial infections. Here we take an expanded view of the overarching threat of antimicrobial resistance (AMR), which encompasses all pathogens against which antimicrobials are used such as bacteria, virus and fungi. Additionally, we recognise that the overuse of antimicrobials is a key factor in the development of resistant pathogens, albeit only one part of a reinforcing combination of new factors that speed up incidence of antimicrobial resistance.
Three factors are providing the primary catalysts for the evolution and emergence of novel pathogens:
These new catalysts have created an environment that allows common infectious microorganisms to more quickly and easily acquire mutations, making them deadlier and able to spread rapidly. This environment is fostering a massive acceleration of Darwin's natural selection.
Governments, the life science industry and healthcare providers have all begun to address AMR and are aware of each other’s efforts, but they are not yet coordinated and integrated. Given the broad and global range of the new catalysts for AMR, we need synchronised multi-sector and multinational collaboration to slow down its development. For collaboration to be successful, not only must it span public and private actors, but it must also involve partnerships and incentives that reach across the continuum of care. This includes detection of novel pathogens and disease trends, development of more efficacious antimicrobials and delivery of healthcare services and medicines efficiently.
To begin, organisations must assess their role in responding to the challenge, understand their own susceptibility and vulnerabilities and recognise the potential opportunities and benefits available to them. Considering the global scale of the AMR challenge, we provide an effective, structured way to view the landscape of organisations, initiatives and interests that are discussed in a recent case study from the World Economic Forum. In this article, we discuss organisational incentives to help drive and sustain collaboration.
The World Economic Forum describes the emergence of antimicrobial resistance ( referred to as ‘antibiotic resistance’) as one of the most significant threats to human health, and one that is becoming more widely recognised as an urgent threat worldwide. The Forum emphasises this threat in ‘The Dangers of Hubris on Human Health,’ a case study in its Global Risks 2013 Report. Although the case study focuses on a specific type of AMR, antibiotic-resistant bacteria, the report authors paint an accurate picture of the consequences for down-playing or disregarding the threat of resistance: “...arguably the greatest risk of hubris to human health comes in the form of antibiotic-resistant bacteria.”
Public health experts and authorities around the world recognise that antimicrobial resistance is an enduring threat – one not likely to go away anytime soon. Despite effective new treatment options or the wisdom and knowledge from past experience - and even with skills and tools drawn from advances in science and technology - the battle between humanity and disease is an unending ‘‘fight for survival.”
The infectious disease landscape is constantly changing, which is demonstrated by the discovery of new pathogens at an alarming rate of three per year. Responding to the threat of novel diseases is an urgent area of need, which includes efforts to slow the emergence of resistant pathogens. HIV, SARS and MERS should remind us that the threat of an unknown infectious disease is real, its transmission is unconstrained by social, economic or geopolitical borders, and it is potentially untreatable using any of the medicines that are currently available.
The good news – global recognition of the problem has led to gradual increases in dedicated resources, focused efforts and strategic initiatives to address the problem. These include an improved antimicrobial product development pipeline, more timely and accurate disease surveillance and rational antimicrobial treatment and use policies.
The bad news – global recognition of the problem has led to the gradual increase in resources, efforts and initiatives that have not been coordinated to optimise impact. Given the breadth and diversity of approaches for addressing AMR, coordination and incentives are both key ingredients for building synergy between sectors, organisations and efforts. Figure 2 provides an overview of these approaches and illustrates the links between solutions.
Figure 2 - Identifying the problems and solutions
Figure 2 presents an integrated view of several different approaches for preventing the emergence of AMR. The system of solutions is derived from a more basic framework, which provides individuals and organisations with a structured approach to evaluate roles, responsibilities, develop partnerships and pursue opportunities towards meeting their mutual goals.
As the WEF case states, “the problem can only be addressed through international cooperation.” Preventing the rise of AMR requires coordinated global action to enable the synergies needed to achieve greater levels of success. Current healthcare treatment policies incent the overuse of anti-microbial products. Like overfishing and global warming, use of antimicrobials faces the tragedy of the commons. We propose a structured perspective that provides a lens through which we can see and understand how the constellation of efforts and entities may be woven together to comprise a response (see Figure 3). Above all, the ‘glue’ needed to hold the framework together is appropriate stakeholder incentives.
Figure 3 - 3-D framework for implementation
Our ability to successfully respond to this invisible global threat to public health depends on applying a more strategic approach as suggested by our framework. Doing so requires:
The medicines we use to treat infectious diseases are becoming increasingly less effective. Unchecked, we risk regressing to a state where we can no longer fend off common infections, let alone novel hospital superbugs, viral pandemics, and even genetically-engineered microbes. Humankind has brought about the three major key contributing factors to antimicrobial resistance:
We have demonstrated that synergy and shared knowledge help organisations recognise and possibly modify current behaviours. By collaborating to coordinate initiatives and programmes, and by identifying shared incentives, they increase the likelihood of success, sustainability, and resource savings.