By Timo Minssen, Kevin Outterson, Susan Rogers Van Katwyk, Pedro Henrique D. Batista, Clare Chandler, Francesco Ciabuschi, Stephan Harbarth, Aaron S. Kesselheim, Ramanan Laxminarayan, Kathleen Liddell, Michael T. Osterholm, Lance Price, Steven J. Hoffman
NB: The below contribution is an extended version of our editorial that was recently published in the Bulletin of the Word Health Organization.
The COVID-19 pandemic has raised awareness of the urgent need to improve the design of health systems, as well as the practical implementation of new strategies and technical solutions to better prepare for future pandemics. These preparations must also consider harms secondary to the pandemic, including the resulting effects on antimicrobial resistance (AMR).
While drug-resistant infections pose a well-known and severe threat to human and animal health, the COVID-19 pandemic is compounding this already problematic situation.
Recent regulatory interventions bring hope that we will not be as unprepared in facing this threat. Moreover, public and private initiatives promoting the development of new antimicrobial treatments, such as the recent AMR Action Fund, will most likely provide a few years of breathing room for innovation to ensure there is a path for new antimicrobials to be developed and delivered to patients in need. But, as important as they are, they will only partly compensate for the unresolved, fundamental problems. Moreover, and most importantly, such initiatives do not change the underlying social, cultural, and economic causes and challenges of antimicrobial resistance on a more sustainable basis.
Although often seen narrowly as a medical problem, AMR is a natural evolutionary challenge harmfully accelerated by social, cultural, and economic factors that cause the misuse, overuse, and abuse of life-saving antimicrobial medicines. The AMR challenge is compounded by inadequate attention to disease prevention and response, global circulation of people and products, differences in industry and market regulations across countries, and a fragile pipeline of new antibiotics and their alternatives.
While some solutions will be found in the discovery of new antimicrobials, most will require rigorous social science research that unpacks the underpinnings of antimicrobial use and identifies solutions that bend the curve towards a sustainable balance across access, conservation and innovation for antimicrobials. Hypotheses abound on possible interventions to reduce AMR, but careful social scientific analysis is required to make real progress (see e.g. here, here, here & here).
To be effective, actions on AMR – including policies, programs, payments, and persuasion – will need to be informed by insights and evidence from the social sciences encompassing a broad variety of disciplines, such as anthropology, economics, law, political science, psychology, and sociology.
From our perspective, current engagement with the full range of social sciences is inadequate. We continue to see silos along disciplinary lines, even within the social sciences. For example, in addition to nurturing collaborations across the health and social sciences, we need to bring the various social science disciplines into conversation with each other. Only then can we generate sufficiently connected architectures of knowledge to overcome obstacles such as: inadequate delivery mechanisms coupled with precarious living that limit access to life-saving antimicrobials; incomplete regulations, inadequate water sanitation and hygiene infrastructures, and behavioral disincentives for the conservation of these precious resources; and insufficient incentives for innovation towards new antimicrobials, related technologies and production and care systems that design-out antibiotic reliance (see here).
Collaboration among social scientists from various disciplines is also needed to help us anticipate unintended consequences of action. For example, promoting awareness of AMR is important, but it can backfire if concerns about drug resistance inappropriately drive the use of less-optimal antibiotics (see here & here).
In the last 15 years, social science research has generated substantial knowledge about the systemic causes of rising AMR and has identified feasible interventions for tackling some of these problems.
A few pioneering interventions have recently been employed, and after the World Health Assembly adopted a Global Action Plan on AMR in 2015, more than 120 countries have developed national action plans.
But, despite this progress, many challenges remain. For example, it is still unclear how to scale-up global access to antimicrobials without scaling-up global resistance, which clinical practices can reduce antimicrobial use without risking lives, and what it will take to de-link the sale price of antimicrobials from the cost of their development (see here, here, here & here). Existing global efforts may be too slow to counter the risk of AMR given the lack of political commitment, the challenge of addressing transboundary collective action problems, and the difficulty in balancing AMR with other global threats (see here), such as COVID-19 or climate change. Yet, just like during the ongoing COVID-19 pandemic, a range of social science disciplines can provide essential analytic tools for developing solutions for such grand global challenges.
To encourage collaboration and to address this ongoing challenge, we have created an International Network of AMR Social Science (INAMRSS) – an open consortium of social science researchers focused on addressing the global challenge of AMR rooted in law, economics, anthropology, public health, epidemiology, sociology, business, history, and many other disciplines.
We believe AMR is only surmountable through efforts that consider social, political and economic factors. We intend to champion social science as part of a broadly defined One Health perspective to inform global initiatives.
The initial work of tracking relevant social science AMR work has barely begun. The Global AMR R&D Hub, which has a stakeholder group that includes representatives from INAMRSS, has built a system to track AMR research investment, but it has not yet started monitoring AMR social science research funding.
We endorse the recommendation of the United Nations’ Interagency Coordination Group on AMR for creating an Independent Panel on Evidence for Action against AMR with appropriate expertise across disciplines, including the social sciences, and with a focus on the ways that humans are driving the AMR problem and can contribute to solutions.
As initial steps, INAMRSS strongly recommends several coordinated initiatives to better identify and implement the most valuable social science insights to support and inform much needed action against AMR.
In particular, we recommend to:
- Track inputs and outputs of social science research including mapping current research spending, research publications, and identifying key gaps
- Include social scientists in AMR research teams, panels, and proposals
- Explore social science interventions to address AMR at individual, population and systemic levels
- Identify key requirements for infrastructure support and international coordination, such as the Independent Panel on Evidence for Action against AMR and the Global AMR R&D Hub
- Use the data generated above to appropriately fund social science research
Only when we consider together the multi-disciplinary aspects of the challenge, will we prevail in addressing AMR.