A “paradigm shift” is needed in the emergency aid sector to deal with antimicrobial resistance (AMR), doctors and campaigners told The New Humanitarian ahead of a major UN summit on the growing global health threat.
Humanitarian crises are often hotspots for AMR – in which germs have evolved to escape the mechanisms that make antibiotics and other antimicrobial medicines work. Experts from Médecins Sans Frontières (MSF) said they believe cases of AMR in crises are rising, making it harder to treat patients – including with medications that used to work – ultimately causing more suffering and death.
The phenomenon “puts many of the gains of modern medicine at risk” by making infections much harder to treat, the World Health Organization (WHO) says. AMR directly caused 1.27 million deaths in 2019 and was a factor in 4.95 million, according to a group of researchers called the Antimicrobial Resistance Collaborators. But that figure is set to rise: The researchers predicted 2050 will see 1.91 million annual deaths as a direct result of AMR, and 8.22 million with AMR as a factor. Between now and then, AMR is predicted to kill 39.1 million people and to contribute to 169 million deaths.
“Fundamentally, we've seen higher rates of AMR because there is a catalytic effect” of driving factors in humanitarian contexts, said Dr Clare Shortall, the lead on antimicrobial resistance strategy at MSF UK. “We can see a lot of death and morbidity that's now associated with it that's going unaddressed.”
A UN General Assembly meeting on 26 September is intended to strengthen global coordination on AMR and will culminate in a political declaration. The event provides the chance for humanitarians to reinvigorate their approach to drug resistance, and to appeal for much-needed funding and political support, the MSF team said.
The declaration, which was published on 9 September, was described as “promising” by MSF, which said it had campaigned for the inclusion of armed conflict and humanitarian actors – a position the NGO said was “contentious among member states”.
But while it recognises “that armed conflicts have a devastating impact on health systems and antimicrobial resistance”, Carine Naim, antibiotic resistance analysis and advocacy adviser at MSF’s Lebanon office, said the charity was “yet to see a clear roadmap to translate those commitments into action that reaches the most vulnerable.”
Why is AMR such a big risk in humanitarian crises?
Antimicrobial resistance thrives in humanitarian crises, experts say.
Disrupted healthcare is often the norm, and – coupled with poor water, sanitation and hygiene conditions, and perhaps low vaccination rates – this contributes “to the spread of infections and subsequently the spread of resistant ones”, said Naim.
These factors can be compounded by the pressures that conflicts and disasters put on healthcare staff, whose knowledge of AMR may already be limited; on antibiotics regulation standards; and on waste management. Infrastructure is often damaged, making it hard to run the laboratories needed to identify germs.
“There's also a fragility of the healthcare system and governance structures as a whole [in crises],” said Shortall. “These drivers, I think, act both directly but also together synergistically, the wrong way, to make AMR even more of a risk.”
Naim said there’s also “a lot of data that is scarce” at the community level. “To understand the transmission better, more data is definitely needed,” she added.
For doctors like Shortall, the delays that AMR causes – due to the time taken up using first-line medicines that then fail – are often “critical”, particularly with blood infections like sepsis, where there is a “golden hour” to apply treatments. Time is also needed studying microbes in laboratories to find out if they are drug-resistant.
And the presence of AMR makes having a trauma injury or amputation even more risky, as standard medications fail. Patients must also stay longer in hospital, straining resources.
Tight humanitarian budgets are also stretched by the “prohibitively expensive” newer medications available to treat AMR infections. It means “using a lot more resources to treat a patient”, explained Naim.
And these drugs – developed for use in high-resource settings – need careful administration, or “you would be driving the resistance even further”, said Dr Anna Farra, medical coordinator of MSF’s Middle East unit on AMR.
How should humanitarians adjust their programming?
There are three pillars of AMR response.
The basics are in the first: sanitation, hygiene, water availability, infection prevention, and control. “These are already interventions that many humanitarian actors do, and these are already underfunded in many humanitarian crises. So that could be a starting point,” said Naim.
The second pillar is ensuring “there is judicious use of antibiotics and there's a proper implementation of the guidelines and update of the protocols in place”, said Naim.
The final pillar is access to microbiology diagnostics and surveillance. This is critical, as AMR cannot be identified otherwise, and it can “remain a hidden” problem that doesn’t show up in humanitarian medical assessments, explained Naim.
But running these facilities – which require reliable power and are vulnerable to supply chain disruption – can be challenging in crises.
“In the majority of the places where we work, we do not find a quality microbiology service in place, and we had to build our own,” said Naim.
There’s also a role for humanitarians outside of the hospital. Civil society groups are
“already embedded in their communities, well aware of the drivers”, said Naim. “They just need some extra push to start and work in some places on the AMR.”
How should policymakers respond?
Responding to AMR in humanitarian crises suffers from a familiar range of problems: scarce funding, siloed responses, and a lack of political will. Despite this, the MSF team said the short-term expenses are far outweighed by the long-term benefits of responding to AMR.
Humanitarians need to collectively think about how to respond, the MSF team said.
A start would be including AMR in humanitarian assessments and response planning, and for AMR considerations to be a basic part of caring for patients.
For now, Naim said baseline assessments on the three pillars above are required for “every project involving advanced HIV care, trauma care, neonatal care [and for] malnutrition hospital centres”. Elsewhere, the International Rescue Committee has surveyed people in Nigeria to better understand how they perceive AMR, she added. But ultimately, “we believe WHO is best positioned to bring together various NGO actors and support the development of an operational framework for this issue”.
Mainstreaming AMR efforts should apply to donors too, said Krystel Moussally, an MSF epidemiologist for the Middle East with MSF’s Lebanon office. Funding for AMR should be “seen as transversal to any activity” in global health activity they fund, she added.
This already happens in the response to the climate crisis – an area where humanitarian and donors have already undergone a paradigm shift – where “a lot of donors will ask you to look at risk and mitigation measures”, said Shortall.
But to get there requires commitment from donors. The UNGA meeting is a chance to focus minds.
Four agencies lead the UN’s work on AMR: the ‘Quadripartite’ of the Food and Agriculture Organization (FAO), the United Nations Environment Programme (UNEP), the WHO, and the World Organisation for Animal Health (WOAH). Their proposals include improved governance and leadership for AMR, financing, targets and monitoring systems, research and development, and “system-wide transformation across human, animal, plant and environmental sectors”.
The declaration said those institutions are playing a “leading role”, and many of their proposals have made it into the document, which also recognises the AMR “challenge for developing countries”.
But the MSF team were concerned about AMR responses being too focused on the Global North. Policymakers often focus on developing new technologies to deal with AMR, but the basic responses are not available in many places, said Shortall. “There needs to be a shift also to consider what is needed in access at low and low and middle resource settings,” she added.
“At a global level, if we want to try to slow down the rate of the AMR pandemic… we definitely need to include low middle-income countries and humanitarian organisations,” said Moussally.
Acting soon is crucial. “We have the time now to prevent and reduce the spread of resistant infections,” said Naim. “We fear that in the long run, it will become itself a humanitarian crisis.”
Edited by Irwin Loy and Andrew Gully.
