Towards a post-antibiotic era

In the midst of growing antimicrobial resistance, the world needs a champion to help combat a potential global health catastrophe. It’s a task that Japan might be up for, Tsung-Ling Lee writes.

The world faces a potential health crisis with the increasing number of microorganisms building their resistance against modern health technologies.

Antimicrobial resistance (AMR) occurs when a microorganism – for instance, bacteria and viruses – stops an antimicrobial drug from working against it. AMR is a significant public health challenge: it is responsible for 700,000 deaths annually, and causes 3.5 per cent of Gross Domestic Product loss globally.

If no concerted efforts are taken by 2050, AMR may result in ten million deaths worldwide – four million of which will occur in Asia. Southeast Asia has been identified as an epicentre for AMR. Intensified urbanisation, food, and agriculture production practices found in Southeast Asia’s megacities magnifies the threat.

Beyond human health, excessive or inappropriate use of antibiotics in animals can also lead to bacteria resistance, posing a global threat to both the health and food security of humans and animals.

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AMR is a shared vulnerability –  no country acting on its own is immune from the threat. The globalisation of food trade, increased international travel, and medical tourism accelerate the spread of resistance.

Recognising the imperative nature of a concerted global effort, the World Health Organization (WHO) has attempted to encourage meaningful political action for more than two decades. In 2001, the WHO selected AMR as the theme for World Health day, and in the same year, released the WHO global strategy on the containment of AMR.

Since then, AMR has garnered much global interest especially in the context of national security, food security, environmental sustainability, and economic development. The 2003 SARS outbreak, the 2009 H1N1 influenza pandemic, and the 2014 West African Ebola outbreak have all contributed to making AMR a global health priority as well.

However, the interconnected nature of the threat means that countries have been forced to depend on each other to safeguard antimicrobial effectiveness. Governments have been turning to global health diplomacy as a channel to push their political agenda as a result.

To compel countries to act, AMR is now commonly framed as a threat to national and global security. “Health is now the most important foreign policy issue of our time,” declared The Lancet in 2006.  In 2016, the UN General Assembly even set forth a political declaration on antimicrobial resistance.

This tactic has spurred a wave of new regional and international initiatives. In 2014, APEC recognised the economic impacts of AMR and established the Tackle Antimicrobial Resistance guideline in the Asia-Pacific Region. ASEAN also made a pledge to follow the WHO’s Global Action Plan.

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The WHO relaunched the Global Action Plan on AMR alongside the Global Antimicrobial Resistance Surveillance System – a mechanism that aims to collect complete data on the world’s antimicrobial resistance trends. Similarly, the G20 Health Ministers issued a declaration for an enhanced response on antimicrobial resistance and established a global AMR Research and Development Hub in 2017.

But despite all this attention, progress remains limited.

Across Southeast Asia, a lack of regulation and governments’ reluctance to enforce stricter laws against over-the-counter antimicrobials have aggravated the resistance. The region is also under pressure to export its livestock and fish products which involves the routine use of antimicrobials in relevant agriculture and aquaculture practices.

The lack of a robust regime has also made it difficult to sustain cooperation and coordination amongst countries. It may be the global health agency, but the WHO struggles with a diminishing budget and an ineffective governance structure. In Asia, health governance is scattered across ASEAN, APEC, WHO, and various UN agencies. Continuous and structured dialogue is impossible to sustain.

With the US’ notable retreat from global health diplomacy, Germany, Indonesia, China, Brazil, and Japan have emerged as key global health players. Though the establishment of the Asian Infrastructure Investment Bank and the Belt and Road Initiative have bolstered China’s ambition to incorporate global health in its foreign policy, scholars remain skeptical about its model of global health diplomacy.

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On the other hand, Japan – the host of next year’s G20 meeting – might be a viable leader of global health. Historically, Japan has engaged deeply in regional health initiatives, and has also often offered technical assistance to multilateral health programs including cooperating with non-state actors in its foreign assistance programs.

Since its G7 presidency in 2016, Japan has continued to show a strong interest in global health leadership and has been prioritising AMR in its political agenda. It spent US $900 million in development assistance, ranking first amongst regional donors.

Though it is sensitive towards the national sovereignty of its aid recipients – as well as having a strong preference to focus on the needs of individual recipients over those of whole countries – Japan’s focus on universal health coverage is central to the containment of AMR.

Some commentators have criticised the national security framing of AMR, with notable objections coming from Brazil, Thailand, and Indonesia. Japan’s political ideology on human security is therefore a welcome alternative to the current national security paradigm.

It remains to be seen how the landscape of global health diplomacy will evolve with Asia’s rising stakes and subsequently growing interest in global health. One thing is for sure – without strong global health leadership, the world will inevitably face the dire consequences of AMR.