2.2 Global impacts of AMR

Inaction on AMR has global consequences, particularly for those living in LMICs who are disproportionately affected by bacterial diseases. People may also face the risk of losing their livestock animals if AMR means that common animal diseases cannot be treated. Figure 1 shows how AMR disrupts the Sustainable Development Goals (SDGs)). (The WHO has published a report about AMR and the SDGs (WHO, 2018).)

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Figure 1 Five ways that AMR disrupts the SDGs.
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This figure shows five ways that AMR could disrupt sustainable development goals:

  • SDG 1, no poverty: AMR could push an additional 24 million people into extreme poverty by 2030.
  • SDG 2, zero hunger: Livestock production in low-income countries would be affected the most. Under a high AMR impact scenario, there is a possibility of a 7% loss in productivity by 2030. Animal protein plays an important role in nutrition for children and women.
  • SDG 3, good health and wellbeing: Effective antibiotics are needed to treat infections. AMR puts patients treating cancer, recovering from surgeries or from diabetic foot ulcers at risk for life-threatening infections.
  • SDG 8, decent work and economic growth: AMR’s impact on global GDP might be as large as the 2008–09 global financial crisis, amounting to losses of $3.4 trillion by 2030.
  • SDG 10, reduced inequality: any reductions in economic growth would be faced primarily by low-income countries. AMR could further widen economic inequality between countries.
Figure 1 Five ways that AMR disrupts the SDGs.

The ethical consequences of inaction on AMR throughout the world include the following points:

  • AMR presents a direct risk to patients: In the presence of AMR, the risks of undergoing surgery will drastically increase if post-operative infections cannot be effectively prevented or treated. This will require clinicians to change their assessments of the benefits of surgical and other medical procedures, balanced against the potential risk of untreatable infection.
  • AMR is not a problem that can be ‘fixed’ Micro-organisms continually evolve and develop AMR mechanisms, from exposure to antimicrobials or via transfer of resistance genes. Acting now can only reduce, not fully eliminate, AMR. Future generations will also have to take continuous actions.
  • AMR is a high-cost burden on the healthcare system: We face a future where common bacterial infections may be untreatable. Patients with multidrug-resistant infections require extended hospital stays, which increase the pressure on health systems overall. Antimicrobials are a relatively cheap intervention; alternatives to antimicrobials are often more expensive.
  • AMR is a food security risk: Antimicrobials are essential for food security. The growing burden of AMR in food-producing animals could affect productivity, decrease the availability of meat, eggs, dairy and fish, increase food prices, and impact food safety.
  • AMR will cost the world: Perhaps some of the most severe impacts of AMR will occur through the impact on economic growth. This will be through lost productivity through days of work due to prolonged infections, death and costs to government. It has been estimated that the cost of AMR to global GDP will be up to US$100 trillion by 2050 if nothing is done (O’Neill, 2014).

Now that we have some ideas about the ethical impacts of inaction, let’s also consider some of the ethical considerations when choosing to take action on AMR:

  • Developing and distributing new antimicrobial medicines: Ethical considerations include asking:
    • Whose responsibility is it to develop new antimicrobials? Is it governments, private companies, or public-private partnerships?
    • Who should pay for this new drug development? Is it the moral duty of high-income countries to develop these drugs if LMICs cannot afford to?
    • How can research and development of antimicrobial medicines be incentivised, while ensuring access to the most vulnerable, especially in LMICs with limited purchasing power for patented medicines?
  • Monitoring and surveillance of AMR and AMU: Ethical considerations relate to the conflict between the individual’s rights to privacy and ownership of personal data and the need to understand AMR and AMU on the population scale. For example, balancing benefits of having local-level indicators of AMR, used to guide treatment and stewardship decisions, against the risk of re-identifying individuals or groups.
  • Animal welfare and responding to AMR: How does action on AMR and AMU conflict with society’s moral duty to care for animals’ health and wellbeing? For example, should we modify the treatment of food animals with antimicrobials to protect the health of people? How do we respond to animals who are in pain and suffering? What impact will this decision have on individuals and communities who rely on animal agriculture?

Activity 7: What would you do about AMU in food animals?

Timing: Allow about 15 minutes

This module has raised several ethical questions about continued AMU in food animals. Using your knowledge of ethics, outline how you would approach deciding whether antimicrobials should be used in food animals.

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Discussion

This is not an easy question to answer, given that concerns about AMU in food animals is not equally apportioned to the different types of uses of antimicrobials (such as treatment, control, prevention and growth promotion). The highest concerns of the public tend to be with uses that are perceived to be ‘wasteful’ or unnecessary, such as growth promotion and prevention, while there is more acceptance of ‘legitimate’ uses such as treatment and control.

From a veterinary perspective, decisions about AMU tend to be complex and multi-faceted, are driven by the veterinary oath, and differ between individuals, sectors and cultures. In determining an ethical dilemma such as AMU in food animals, it is good practice to not only take a values-based approach but also to consider available scientific evidence of the impact of decisions to restrict certain uses or certain antimicrobials.

2.1 Ethical considerations of AMR in animal health and production

2.3 AMR surveillance and the ethics of privacy and confidentiality