1. Why we need transitional justice

Planning a sustainable future with antimicrobial resistance (AMR) raises significant justice challenges. From a justice perspective, the time frames and dynamics of AMR make it particularly challenging.Footnote ¹ In this context, the AMR Working Group has proposed using the just transition framework to tackle this global challenge.Footnote ² The idea of just transition was originally developed in the context of the U.S. labor movement, aiming to ensure that workers’ interests were recognized during transitions toward sustainable forms of production.Footnote ³ This framework addressed conflicts of justice between workers’ interests, which are based on the status quo, and the public’s interests in building a more sustainable economy. Such conflicts can be understood as those between status quo interests and future-oriented interests. In the context of AMR, analogous conflicts emerge, including the clash between farmers’ interest in maintaining a business-as-usual practice of antimicrobial use and the public interest in preserving their long-term effectiveness.

In this brief, we recommend enhancing the just transition approach by complementing it with the transitional justice framework. In the climate transition, debates originally based on the just transition framework have been strengthened by including transitional justice perspectives, especially in relation to accounting for historical emissions in carbon budget allocation and in designing the institutions and mechanisms that govern the transition.Footnote ⁴

Transitional justice has emerged as a multidimensional practice aimed at addressing past political tragedies and building a more equitable future. This approach includes mechanisms such as the Truth and Reconciliation Commission established after apartheid in South Africa, the Nuremberg Trials after World War II, and the Processes of Memory, Truth, and Justice implemented after the dictatorship in Argentina.Footnote ⁵

Although the contexts of paradigmatic transitional justice cases and the AMR context differ considerably, transitional justice can be understood as a problem-responsive value. Under this conception, transitional justice is not tied to a specific historical setting but rather to the circumstances that render it necessary and possible.Footnote ⁶ From certain perspectives, the circumstance that renders transitional justice necessary is the conflicts of interest over how a transitional society should address the past while simultaneously building a better future.Footnote ⁷ In paradigmatic cases of transitional justice, a key question is whether to address past injustices when building a new future—as Argentina did in the Trial of the Juntas—or to leave the past behind, as exemplified by the Spanish Amnesty Law.Footnote ⁸ Addressing this question may involve assigning responsibility for past wrongs or allocating the costs of the transition (transitional burdens) based on how different actors contributed to the past regime, even if they did not directly commit wrongs or bare responsability for them.Footnote ⁹

Similarly, one circumstance that makes transitional justice necessary in the context of AMR is existence of opposing views on the role the past should play in planning the transition. For the AMR transition to be just, should we consider how past injustices shape the risks and vulnerabilities we have to manage? Should we assign responsibilities or allocate burdens based on past behavior that has contributed to this crisis? The AMR literature and practice have not yet fully acknowledged this conflict, though it can be traced through concerns about health inequalities linked to past injustices and colonial legacies. For example, these tensions can be observed in the literature on the vulnerabilities and risks created by modernization programs introduced by colonizers, which promoted antimicrobial use in agriculture.Footnote ¹⁰

Transitional justice addresses not only disagreements over how the past should shape the aftermath, but also the underlying disagreements and practices that initially triggered the crisis that the transition seeks to address. In paradigmatic cases of transitional justice, these disagreements might lead to social conflict (e.g., civil war) or an authoritarian response to that conflict (e.g., dictatorship). In this regard, addressing the roots of the crisis is a key feature of transitional justice aimed at building guarantees of non-recurrence, namely, making the structural changes necessary to ensure the same or other events arising from comparable underlying causes do not happen “never again.”Footnote ¹¹

In the AMR context, transitional justice requires identifying the structural factors that served as the roots of the crisis. Guarantees of non-recurrence might require identifying the constraints that any biomedical innovation should face once it is known that it can lead to the tragedy of the commons, as in the AMR case, if appropriate governance instruments are not in place from the beginning.Footnote ¹² In establishing these constraints, transitional justice plays a role in adjudicating the conflict between the interests of the beneficiaries of biomedical innovation and the risks of creating a scenario that could lead to a tragedy of the commons.

Applying the transitional justice framework to the AMR transition requires confronting specific justice conflicts: how the past should be considered in planning the transition, and how the emerging regime should be designed to minimize the risk of recurrence. The following sections highlight key research gaps that the sciences and the humanities should prioritize in order to better identify the conflicts that an AMR transition guided by transitional justice principles should adjudicate.

2. Knowledge and acknowledgement

To implement the transitional justice framework in the AMR transition, it is essential to consider a timeline encompassing the past, present, and potential future scenarios. Data for modeling the transition are limited, particularly regarding future scenarios that combine normative and empirical aspects. Although the timeline presented in Figure 1 is partially intertwined with empirical evidence, it serves mainly as a thought experiment to identify the justice challenges that transitional justice can address.Footnote ¹³ The absence of supporting data or the possibility that it may not be structured optimally for justice-related analysis can be addressed, as others have suggested, by establishing a body analogous to the Intergovernmental Panel on Climate Change (IPCC) in the climate context.Footnote ¹⁴ To make both the timeline and the transitional justice framework more concrete, it is helpful to consider the historical development of antimicrobials and the early emergence of resistance.

Figure 1. AMR past, present, and futures.

At some point in the past, antimicrobials were developed, and people quickly became aware of antimicrobial resistance (AMR).Footnote ¹⁵ The first case of resistance—to Salvarsan—appeared just fourteen years after the commercial deployment of antimicrobials.Footnote ¹⁶ This historical perspective is not merely descriptive—it also informs how we understand justice in the AMR transition. In particular, it raises questions about whether and how past knowledge of AMR should influence present-day decisions and burden-sharing.

As a problem-responsive value, the role of transitional justice is to adjudicate conflicts between those who believe the past should influence how we plan the transition and those who advocate for a transition based solely on forward-looking considerations. For those who accept backward-looking considerations, a relevant question is whether historical knowledge about AMR should carry weight in the allocation of transitional burdens.

Although the debate on the epistemic conditions of responsibility is complex, we can consider a minimal position within backward-looking approaches, namely, that awareness of AMR is a condition for being held liable for greater transitional burdens.Footnote ¹⁷ If this view is to play a meaningful role in planning the transition, it becomes essential to examine how awareness of AMR has spread globally and how it intersects with other factors, such as the capacity to prevent the harmful outcomes of the (mis)use of antimicrobials.

The WHO’s 1998 Global Strategy for the Containment of Antimicrobial Resistance marked the organization’s first major step in formally recognizing AMR as a global health issue. The strategy urged member states to implement measures for AMR containment. However, this first strategy did not incorporate any justice considerations or provide any reference to historical perspectives on the structural drivers of resistance. The 2015 WHO Global Action Plan on Antimicrobial resistance formally called on countries to take action against AMR, including measures for infection control and the prudent use of antibiotics.Footnote ¹⁸ The plan acknowledges the unequal resources that countries have to combat AMR—for example, the limited access to “last-resort” antibiotics in low- and middle-income countries (LMICs)—but it remains firmly forward-looking in its overall approach. In 2016, the high-level meeting of the UN General Assembly issued a Political Declaration on AMR. Footnote ¹⁹ This resolution marks the point at which AMR can be considered formally acknowledged at the highest political level, signaling the emergence of new liabilities and burdens—including those related to the protection of the human right to health. Although the resolution advances equity and shared responsibility principles, it does so in an entirely forward-looking manner, without giving weight to historical injustices or to the historical drivers of AMR.

3. Causal contributions and benefits

Over the past twenty-five years, antibiotic consumption rates in LMICs have been converging with—and in some countries even surpassing—those observed in high-income countries (HICs).Footnote ²⁰ Yet it remains unclear how the historical contributions to, and benefits of, antimicrobial use have been distributed among countries. To plan a transition toward sustainable antimicrobial use that also accounts for the past, it is necessary to identify the historical causal contributions to AMR. This requires not only mapping patterns of antimicrobial misuse but also assessing whether such practices enabled development and economic growth for some, or instead reflected deeper structural injustices—for example, the limited capacity for effective infection control in low-resource settings.

Further studies are needed to establish how the benefits of the historical (mis)use of antimicrobials have been distributed across regions. Since the use of antimicrobials in human medicine helps prevent and treat infections, it is reasonable to assume that countries with consistent access have benefited—at the very least—through reduced medical costs and fewer losses in productive work hours. To understand how the past has shaped the current landscape of AMR—and how this should inform the allocation of transitional burdens—it is also essential to consider whether, and in what ways, HICs may have benefited from the limited access to second- and third-line antimicrobials in many LMICs. These benefits could range from the conservation of antimicrobial effectiveness to the ability to influence or control prices.

In addition, the burden of AMR is unevenly distributed both among and within countries.Footnote ²¹ It is acknowledged at the UN level that LMICs disproportionately shoulder the burden of AMR.Footnote ²² However, the historical injustices that may have contributed to this crisis—including past deaths, adverse health outcomes, and the economic losses attributable to them—remain largely absent from the relevant discussions.Footnote ²³ Although it is well recognized that AMR places a significant burden on the global economy—through reduced productivity and increased treatment costs—systematic studies on the historical costs of AMR, their distribution across countries, and the extent to which they can be attributed to specific practices and actors are still lacking.Footnote ²⁴

Identifying and recognizing the historical drivers of AMR—particularly those rooted in historical injustices such as colonization—is essential for shaping a transition grounded in transitional justice. One example of such a driver linked to historical injustice can be found during British colonial rule in Uganda, when the government actively promoted the (mis)use of antibiotics in veterinary medicine and agriculture as part of its agenda of “progress” and “modernization.” Moreover, colonization has shaped vulnerabilities and risks related to AMR in Uganda across generations by displacing or dismissing indigenous strategies for managing infectious diseases.Footnote ²⁵

The identification and recognition of structural injustices inherited from the past are also important for determining just pathways for the transition. The Nubian case exemplifies how current structural injustices, which are rooted in a history of colonial oppression, can cause a transitional measure to become a means of perpetuating those very injustices. Nubians were brought to Kenya over a century ago as part of the British colonial army, but refused to fight in an uprising. As a result, the British denied them land rights, and subsequent Kenyan governments also failed to recognize them. This led to discrimination across generations, and today, many Nubians still struggle to obtain official ID cards. In this context, transitional measures that require an ID to access antibiotic prescriptions reinforce this long-standing structural injustice rooted in a historical injustice.Footnote ²⁶

4. Transitional losers and resistance mayors

Another critical question for the AMR transition is: who are the transitional losers—those who are made worse off by the transition? In the AMR context, an example is the food industry, which will need to modify production practices to reduce the (mis)use of antimicrobials, potentially incurring significant economic costs.Footnote ²⁷ While the concept of transitional losers is central to the just transition framework, the transitional justice perspective adds the insight that their identity may also be shaped by historical factors, such as past contributions to the crisis, the legacy of injustices, or failures to comply with precautionary norms.

The transitional justice perspective deepens the just transition framework by refining the problem of transitional losers. It raises normative questions such as whether actors who have historically contributed to, or benefited from, antimicrobial (mis)use should receive compensation for the burdens associated with transition, or whether justice instead requires that they shoulder those costs in full. The answer to this question may be conditioned by considerations of political or practical feasibility, but its normative significance remains central to guiding action and advocacy. A second key question is whether there should be a limit to the burdens the AMR transition can place on transitional losers—such as protecting their basic needs—even if they contributed to or benefited from the crisis. A further issue is whether that limit should itself be historically informed by the very practices, policies, or institutions the transition seeks to overturn.

Identifying who the transitional losers are and how they contributed to the AMR crisis is key to deciding how the past should shape the distribution of transitional burdens. While this raises many complex issues, such as attribution problems, there are some clearer instances where transitional justice efforts could begin to operate in this respect. Similar to the concept of carbon majors in the context of the climate transition, certain actors can be readily identified as major contributors to AMR and beneficiaries of the commercialization of antimicrobials. Historically, the pharmaceutical industry has developed and marketed antimicrobials with awareness of resistance risks, while also profiting from their sale. This may justify holding these so-called “resistance majors” liable for bearing higher transitional burdens.

5. The missing consensus on goals, metrics, and values

Although numerous governance tools have been developed—along with approximately 171 national AMR action plans—there is still no global agreement guiding the AMR transition that is comparable to the Paris Agreement for climate change.Footnote ²⁸ Such an agreement could offer significant advantages in steering coordinated efforts and engaging communities in the planning, monitoring, and evaluating AMR containment.Footnote ²⁹ Moreover, the recently adopted Pandemic Agreement only sets a broad objective of enhancing efforts to tackle AMR. It merely encourages each party to progressively strengthen surveillance and risk assessment measures, while sharing relevant findings across sectors.Footnote ³⁰

Currently, there is no unified global goal or consensus on how to measure AMR or its containment.Footnote ³¹ This lack of agreement limits the effectiveness of initiatives such as the Global Antimicrobial Resistance Surveillance System (GLASS). Without universally accepted metrics and methodologies across countries, disciplines and organizations, GLASS cannot yet fully coordinate global surveillance efforts.Footnote ³²

Research gaps and governance limitations are deeply interconnected and hinder the possibility of a just transition informed by transitional justice. Identifying the goals, establishing a unified metric, and budgeting the transitional burdens are necessary first steps in transitional justice. This then allows us to address how these burdens should be allocated and, subsequently, whether the allocation scheme or guiding principles should be historically informed, and what weight historical injustices—and the present structural injustices arising from these—should have. As others have suggested, establishing a body similar to the IPCC for the AMR context can facilitate the process of addressing these gaps.Footnote ³³

6. AMR and future generations

Since we are dealing with numerous research and policy gaps, we must rely on our thought experiment again. Let us assume that a scientifically and ethically grounded goal, along with pathways for the AMR transition, has been defined as part of an international agreement — similar to the Paris Agreement in the context of climate change. These pathways might include stewardship measures, as well as structural equity measures, such as improving sanitation. From this point, we can trace various future scenarios shaped by different levels of compliance with the goals and pathways agreed (Figure 1).

This is, of course, a simplification of the complex future scenarios of the AMR transition. AMR may be even more complex than climate change. Unlike greenhouse gases, which accumulate physically in the atmosphere regardless of their source, AMR arises from numerous contributors that are entangled in complex ways and interact uniquely with evolutionary pressures.Footnote ³⁴ Part of this complexity, however, could be mitigated through the adoption of unified methods and metrics.Footnote ³⁵

In assessing transitional pathways, accounting for tipping points within modeling is essential. It is not yet clear how tipping points should be characterized for the AMR context, and this may be challenging. Footnote ³⁶ Elements for defining tipping points, such as irreversibility, should be revisited and contextualized in the AMR context, taking into account genetic and evolutionary factors alongside social and ethical dimensions.

Let us return to our thought experiment depicted in Figure 1: in the worst-case, business-as-usual scenario—where antimicrobials continue to be used without meaningful changes—resistance tipping points are reached sooner. Increased compliance, in contrast, delays these tipping points. Time is, therefore, a critical factor in assessing transitional pathways. Establishing priorities helps determine what to do first, when to implement each measure, and how long it will take to achieve the projected outcomes. Both soft and hard feasibility constraints shape the time required for each measure needs to produce the expected outcome.Footnote ³⁷ Time also affects the extent to which adverse health outcomes can be avoided through the effective use of antimicrobials, as well as the costs associated with such interventions. In this sense, a measure’s outcomes and costs vary depending on how close it is to a tipping point. In this context, the transitional justice approach raises the question of whether historical injustices and their present legacies should weigh in when deciding what to do first, even if this path promises a suboptimal outcome compared with a non-historically informed pathway.

These temporal dynamics become even more ethically complex in non-ideal scenarios, where partial compliance may lead to unevenly distributed outcomes across generations. In non-ideal scenarios, some generations might even benefit from previous generations’ non-compliance with transitional measures. This might be the case, for example, if, after some time, resistance reverts due to the loss of resistance genes and antimicrobials regain their effectiveness.Footnote ³⁸ In this situation, transitional justice asks whether these generations should be seen as beneficiaries of a (future) historical injustice and, if so, whether that should affect the maximum burden they are expected to bear. Affirming the latter question could demand a specific ethical justification, given that the maximum share is connected to safeguarding the minimum basic needs.

In any future scenario, we must address the question of how to allocate the burdens of the transition among future generations—and whether historical responsibility should play a role in that allocation. Even in scenarios of full compliance, complex transitional justice challenges persist. One such challenge involves the potential emergence of an “overshoot generation”—a future generation that, despite full present-day commitment to the AMR transition, disproportionately bears the burden of past inaction. In this scenario, it will be necessary to identify appropriate measures to support this generation in reducing the harms and risks they will face. In this context, prioritizing harm reduction for this generation may take precedence over addressing other historical injustices. Moreover, allocating resources among the members of the overshoot generation is a question that could be informed by considerations of historical injustices.

7. Call for an AMR transition with transitional justice

The transitional justice framework offers a means of integrating historical considerations into the construction of a sustainable future with AMR. Yet, claims based on historical injustices have not yet been meaningfully incorporated into international discussions on how to manage AMR, nor into the research priorities addressing it. A justice-sensitive approach to AMR research should explore how the contributions, benefits, and costs of antimicrobial (mis)use have been historically distributed at the global level.

As with the climate transition, once the AMR transition progresses, major stakeholders—particularly from HICs and industry—are likely to advocate for exclusively forward-looking approaches in order to minimize their share of the transitional burdens. The transitional justice framework not only provides a heuristic for historically affected populations to bring past injustices into the debate, but also outlines an interdisciplinary research agenda to generate the evidence necessary to substantiate those positions.