AMR: a threat outpacing awareness
Addressing the global public health threat of antimicrobial resistance (AMR) is near and dear to those of us practicing in infectious diseases and public health. Strategies to track and report resistance and to slow the emergence and spread of drug-resistant organisms through antimicrobial stewardship and infection prevention dominate the pages of our journals, keynote lectures, and online discourse. In each of these forums, we passionately communicate about current challenges and novel discoveries in addressing drug resistance. But this enthusiasm remains largely self-contained within our field merely scratching the surface of public, clinician, and policy decision-maker interest, precisely the groups whose engagement is needed to address the increasing toll of AMR.
While infectious diseases experts make up < 0.1% of the population, the other 99.9% are relatively unaware of, let alone mobilized to address the growing threat of AMR. Public opinion research shows that only one quarter (24%) of respondents have ever heard of AMR, and once explained, 57% believe there is not much one can do about it. Reference Crago, Alexandre, Abdesselam, Gravel Tropper, Hartmann and Smith1 On the other hand, while most healthcare professionals understand the concept of AMR, their sentiments are similarly ambivalent. There is a tendency to blame others—other regions, clinicians, disciplines, and even patient pressure, for antimicrobial overuse—a key driver of AMR, thereby reducing their sense of personal responsibility. Reference McCubbin, De Jong, Smid, Ida, Bodaneze and Anholt2,Reference Zetts, Garcia, Doctor, Gerber, Linder and Hyun3 Importantly, clinicians feel that other health problems (such as obesity, diabetes mellitus, opioids, smoking, and vaccine hesitancy) are more important than AMR.
AMR is also an increasingly urgent issue in agriculture and the environment, driven by the widespread use of antimicrobial agents in livestock, aquaculture, crop production, and in companion animals. This practice fosters the emergence of resistant bacteria, which can spread through food, water, soil, and air. Environmental contamination from manure, agricultural runoff, and wastewater further amplifies the spread of resistance genes, disrupting microbial communities, and impairing ecosystem functions. Reference Larsson and Flach4 Globally, efforts to manage AMR are hampered by competing interests (eg, industry lobbying around the use of antimicrobials in animals), regulatory gaps (eg, the ability to purchase antimicrobials without a prescription and a lack of regulation around the quality and consistency of antimicrobials in some countries), incomplete surveillance (eg, reliance on sentinel sites rather than comprehensive tracking), and poor coordination across sectors. A One Health approach integrating human, animal, and environmental health is essential to reduce risks and safeguard both public health, animal health, and ecosystems.
Global pledges, local gaps
While international leaders have declared AMR a significant public health threat and committed to action to address AMR as part of the UN General Assembly High Level Meetings on AMR in 2016 and 2024, 5,6 the response in developing and deploying action plans has been highly variable between and within countries. Reference Charani, Mendelson, Pallett, Ahmad, Mpundu and Mbamalu7,8 In-principle commitment is often not reflected in the level of funding, resourcing, measurable goals and strong policy instruments needed to truly address the AMR crisis. 9 While several countries have made important strides to address AMR (eg, strengthening global AMR surveillance, 10 AMR and antibiotic use reporting requirements, 11 removal of growth promotion claims from medically important antimicrobials in veterinary practice), 12 these changes are inconsistent across the globe, generally lack enforcement mechanisms, and do not address the full range of strategies needed to limit unnecessary antibiotic use.
Key challenges continue to limit meaningful action. On a global scale, addressing AMR requires sustained policy development and implementation over many years, but this long time line often exceeds the political cycle. As with all public health preventative efforts, the benefits are less visible (eg, not acquiring a resistant organism) and often get passed over for more tangible quick wins (eg, reducing surgical wait times). As a result, there is limited appetite to invest in strategies whose impact may not be realized during a given political term. Further, the role of science in supporting decision-making is increasingly being eroded. The complexity and nuance required to understand and address AMR, coupled with political movements shifting the focus away from science-based decision making makes it challenging to ensure AMR ranks high on the political agenda. Reference Marleau and Girling13,Reference Rose, Sutherland, Amano, González-Varo, Robertson and Simmons14 Clear, coordinated strategies are needed now, more than ever, to elevate AMR as a political and public priority both locally and globally.
Strategies to move AMR beyond the echo chamber
Complex problems call for multi-faceted solutions. While the growing threat of AMR seems daunting, there are promising, innovative, and feasible strategies to mitigate the global spread of AMR. The following are four key strategies needed to move beyond the AMR echo chamber and influence policy change and public awareness:
Improve knowledge translation
Despite the extent of the threat, AMR is poorly understood. Improved knowledge translation will ensure our research resonates with the public and policy makers. Understanding the interests of our various audiences is needed to ensure we meet them where they are, and our messaging resonates. Reference Krockow, Jenkins, Mkumbuzi, Flusberg and Tarrant15 Simple, yet successful, approaches include stories, metaphors, policy briefs, media releases, and infographics that summarize key points for targeted audiences. Visual abstracts are digestible summaries of research findings, which increase engagement and readership Reference Ibrahim, Lillemoe, Klingensmith and Dimick16 and may be a promising approach to increasing the likelihood our work impacts policy change.
Two heads are better than one. Multinational, cross-sectoral efforts including, but not limited to those by International Center for AMR Solutions (ICARS), 17 VALUE-Dx (industry and nonindustry collaboration to improve adoption of diagnostics to combat AMR), 18 and Joint Programming Initiative on AMR (JPIAMR) 19 aim to bridge the gap between research and the real world, and support collaborative AMR mitigation strategies with full integration of knowledge translation into their work. Ongoing resourcing of such collaborative and large-scale initiatives is needed to ensure sustainability of this work.
Policy change can occur from the top down (government initiated), bottom up (evidence or public opinion based policy changes), or co-produced (where science and policy makers work together to develop impactful evidence-informed policy). Reference Boaden20 Improving our efforts in knowledge translation can affect policy change from all of these directions.
Invest in public engagement and education
Mobilizing the general public on the importance of addressing AMR allows for change from the bottom up. Improved awareness about AMR and its impacts is foundational to action. Many AMR awareness campaigns have been launched, but few have been systematically and rigorously evaluated. Those that have been studied, suggest that multimodal approaches are most effective, focusing on key take-aways (eg, antibiotics don’t work for most upper respiratory tract infections), providing messaging to both professionals and patients (addressing both supply and demand), including both active (eg, face to face hands-on learning) and passive approaches (eg, mass media) and pairing with other strategies like audit and feedback. Reference Gilham, Pearce-Smith, Carter and Ashiru-Oredope21,Reference Cross, Tolfree and Kipping22
When discussing AMR, it is not just what you say, but how you say it. Wellcome’s Reframing Resistance report provides five tangible and impactful suggestions to communicate about AMR: 23 (1) frame AMR as undermining modern medicine (eg, AMR makes common infections difficult to treat and prevent), (2) explain the fundamentals succinctly (eg, AMR develops in microbes, not humans, so it can pass to your friends and family), (3) emphasize that this is a universal issue (eg, AMR can affect you), (4) focus on the here and now (eg, AMR is not just a future threat; it is happening now), (5) encourage immediate action (eg, AMR is solvable, provide audience-specific calls to action). While the population health consequences of AMR are staggering, a fear-based approach may capture attention but could be counter-productive if too heavily emphasized. Reference Krockow, Jenkins, Mkumbuzi, Flusberg and Tarrant15,Reference Nerlich and James24 More balanced framing, of both population and individual-level impacts, enhancing personal relevance, and focusing on solutions may be more likely to result in action.
World AMR Awareness Week is one opportunity to share these key messages and draw attention to this important cause. Reference Langford, Matson, Eljaaly, Apisarnthanarak, Bailey and MacMurray25 Color campaigns like “Go Blue” and “Go Purple” can be coupled with best practices in AMR messaging to increase awareness among the public. During WAAW and throughout the year, social media provides an opportunity to meet the public where they are and use entertaining and engaging approaches such as personality quizzes and social media campaigns. Reference Langford, Laguio-Vila, Gauthier and Shah26
Unify efforts across the One Health continuum
AMR is not just a human health problem. Antimicrobial resistant organisms and their genetic material move freely between the environment, animals, and humans, presenting a risk to planetary health. This calls for a One Health approach in which experts and practitioners work across sectors to reduce antibiotic overuse, deploy novel treatment and prevention solutions, and track AMR together. The One Health framework also offers an opportunity for cross-disciplinary collaboration to ensure strong advocacy with consistent messaging and a unified voice. Similarly, AMR is not the responsibility of a single discipline or industry. Efforts to address AMR should coalesce between healthcare (both human and animal), public health, environmental health, and private industry including pharmaceutical and diagnostics manufacturers. For example, the University of Calgary hosts transdisciplinary initiatives such as the One Health: AMR and Emerging Zoonoses Conference and the Canadian AMR Network to bring together experts and trainees in human, animal, and environmental health to develop scalable strategies to address these growing health threats. Such efforts taken to develop an improved and unified understanding of the environmental pathways of AMR, strengthen risk-based approaches, and support targeted preventive actions to mitigate and control AMR health impacts.
Develop stronger science-policy partnerships
While the vastly growing volume of peer reviewed literature on AMR mitigation is impressive, little of this literature ever makes its way to a policy maker’s desk. To make meaningful progress, a stronger and more coordinated science-policy partnership is needed. AMR is a shared problem requiring shared responsibility. Closer working relationships between scientists and policymakers improve the chances that science will actually be operationalized into policy changes. These relationships must be built on trust, mutual understanding, and a shared language that bridges scientific complexity and policy priorities (eg, impacts of AMR on productivity, healthcare costs, wait times may resonate strongly with policy makers). Actions to improve the science-policy interface include joint issue identification and co-developing a common understanding of the science-products to be produced (including timelines, relevance) to inform the decision-making processes. The AMR Policy Accelerator is an exemplary effort of bridging the gap between science on AMR and policy. 27 This Wellcome Trust-funded initiative is home to the World Health Organization Collaborating Center on Global Governance of AMR, and provides governments and international agencies with recommendations to support high yield policy decisions (eg, prioritization of AMR mitigation interventions, strengthening AMR policy making capacity). With such strong science-policy partnerships, we can develop policies that are not only feasible and evidence-informed, but also impactful and sustainable in the fight against AMR. This scale of partnerships requires an ongoing investment in time, resources, and expertise to be successful.
Now is the time to move beyond the echo chamber and engage the other 99.9% in the conversation about AMR. To do so, we will need to employ evidence-based communication strategies and break down silos across disciplines and sectors. Only when the public and policy makers are proactively engaged and informed about AMR, can we make substantial strides to mitigate and reduce this threat.
Acknowledgements
The authors would like to thank Kathryn McDonald, MPH, for her review of this manuscript.
We would like to acknowledge the following individuals for their efforts in coordinating the Powers of Policy & Public Engagement session at the University of Calgary One Health: AMR & Emerging Zoonoses Conference:
Stephanie Bishop, Assistant Professor, Western University
Bradely Dubrule, Researcher and Technician, University of Calgary
Benson Weyant, Infectious Diseases Physician, University of Calgary
Financial support
None.
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