AMR Awareness Week (Day 4): "One Health Stakeholders’ Best Practices" – what's that all about?
The WHO state that World Antimicrobial Awareness Week (WAAW) is intended to encourage (amogst other things “best practices among … One Health stakeholders and policymakers, who all play a critical role in reducing the further emergence and spread of AMR.” In this blog, we will explore this term ‘One Health stakeholders’, examine who they are, how their practices might be improved, and the associated implications for our exposure to anti-microbial resistant pathogens if they don’t improve their act.
This is relevant because this year’s official theme for the week is “Preventing Antimicrobial Resistance Together” – in particular “working together collaboratively through a One Health approach”. Note TOGETHERNESS is seen as key. It’s not that helpful as statement unless we know who these One Health ‘stakeholders’ (as they are termed in the world of public health) are. It's also not helpful if some stakeholders are pulling in different directions.
So firstly, what exactly is this ‘One Health Approach’?
So what does ‘One Health’ means’ exactly? Well, the term ‘One Health approach’describes “an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals and ecosystems”. Grand words, but hardly very specific!
It further (and very importantly) recognises “that the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and interdependent". More grand words, and massively aspirational, but how exactly does this relate to AMR?
Well, it very nebulously identifies that, while health, food, water, energy and environment are all vitally important topics with sector-specific concerns, they converge in the nature of “health challenges such as the emergence of infectious diseases, antimicrobial resistance, and food safety”.
So this considered a very big deal idea which does relate to AMR – and it’s theoretically holistic in the most holistic sense of the word because, by linking humans, animals and the environment, this ‘One Health approach’ should help to address the full spectrum of disease control – from prevention to detection, preparedness, response and management – and so contribute to improved global health security.
But is this working? It can hardly do so if there is no appropriate definition of the vital ‘one health stakeholders’ who are needed to take the necessary action ‘collaboratively!
AND Who are these ‘One Health Stakeholders’ referred to by the WHO?
Well, it turns out that it’s pretty much all of us and everything! A 2014 Pubmed article entitled ‘Stakeholders in One Health’ defines them as follows:
“The stakeholders in One Health include the ultimate beneficiaries (i.e. animals, people and the environment) and the organisations that work to protect them (i.e. research institutes, government ministries, international organisations and professional bodies).”
It has to be said that this amounts to being quite a collective – basically its all of us (with our complex conflicting interests) along with all of the natural world, along with all the organisations you can imagine who are involved in preserving the food chain, maintaining political and economic stability, salvaging the environment, and preserving human health (and more as we will see). And it’s all quite a bit too vague for our taste.
We say it’s vague because we strongly suspect that this really relates to the risks to humans of zoonotic (animal) disease spreading between species and so (by implication) the consequent threat to human health. And if this is the case, it’s actually a lot more human-centred than it’s spun to be, and what's more there are other important stakeholders who need to be brought into the collective beyond those defined above.
The fact that this term is so generally vague particularly concerns us because we suspect that it is in relation to the shady avoidance of good One Health Approach practices that we may have most to fear from AMR in the coming years.
We are all acutely aware now of this risk courtesy of the SARS-CoV-2 virus which (whether by accident or design) definitely came from horseshoe bats and somehow morphed into a state in which it could transmit between human beings. In this sense COVID-19 is a classic ‘One Health’ issue (however it arose). In respect of AMR, however, COVID-19 is not a major player and hopefully will remain that way.
As we see it, in respect of AMR, the ‘One Health’ doctrine appears to principally relate (although not explicitly enoyugh) to husbandry, farming and veterinary practices, and so this is the rabbit hole that we are going to go down in this blog because it is a very deep and dark one.
Zoonotic AMR that spills over into human infections
It’s actually Wikipedia which has sent us in this direction by describing One Health as an approach calling for ‘the collaborative efforts of multiple disciplines working locally, nationally, and globally, to attain optimal health for people, animals and our environment” and states that is defined as such by the One Health Initiative Task Force (OHITF). Specific to AMR, however, Wikipedia adds that “[The approach] developed in response to evidence of the spreading of zoonotic diseases between species and increasing awareness of "the interdependence of human and animal health and ecological change".”
This takes us straight into the complexities of intensive farming, of the need to feed the world, of veterinary medicine and even of smallholding farming which all together provoke the often-indiscriminate practice of using of antibiotics in industrial quantities both to generate productivity in the food chain (and so supply us humans with food) and generate profit for both farmers and purveyors of their produce. And (of course) it also provides profits to the manufacturers and suppliers of these antibiotics. Driven by the pressure to produce (which itself promotes health for the human population since under-nutrition obviously does the opposite), and by this secondary pressure for profit, there is now a well-recognised problem of AMR already developing in animal populations, with the consequential constant risk of spill-over events from a resistant infectious agent emerging that, by sorry happenstance, becomes highly infectious to humans.
In the previous blog we identified that In the USA over 70% of medically important antibiotics are used in agriculture, mostly for disease prevention in intensive husbandry and for growth promotion. Given that this introduces such a significant risk of provoking AMR strains, it’s worth adding that of the one-and-a-half thousand diseases now recognised in humans, approximately 60% have been characterized by their movement across species lines. Moreover, over the last three decades, approximately 75% of new emerging human infectious diseases have been zoonotic. So spill-over infections are not rare and can be very serious indeed – as we know now full well, even when they have low case fatality ratios as with COVID-19 disease.
The sorts of pathogenic bacterial microbes that authorities are currently most alert to in respect of AMR are ones like salmonella, campylobacter, staphylococcus aureus (which 80% of us, we should note, already have resident in the lining of our noses) and E.coli too, but of course they are also highly alert to avian flu which can easily spread from farming into wild bird populations who migrate across thr world. But this doesn’t just apply to livestock production of course, it also applies to aquaculture and fish farming which already has a questionable reputation in respect of its environmental impact as well with no real biosecurity possible through the holes in the netting.
It should be added here that many countries have already been proactive in taking steps to ban the practice of using preventative low-dosed antibiotic in animal feed (which also acts as a growth promoter, of course, which adds to its appeal for farmers), but this hasn’t suppressed the problem often because of conflicts of interest amongst other stakeholders in feeding the world. In Europe, for instance, legal challenges to these policy decisions from the pharmaceutical industry have seen significant delays in the passage of such legislation. At the other end of the economic scale, in Bangladesh, antibiotic use in animal feed was robustly banned, but pharmaceutical companies quickly spotted a simple loophole and switched production (and heavily marketed it to small-scale farmers) to antibiotics that could be administered instead through the animals’ water supply.
We need to be acutely conscious of the influence that this industry (which has a disproportionate number of lobbyists acting on its behalf) has on our politicians and our media. Anyone who doubts this only needs to consider some of the inexplicable decisions made by both national and global authorities in the course of the last three years in response to the coronavirus.
The Pharmaceutical Industry’s contribution to the problem
Plainly the pharmaceutical industry (which we now have comprehensive evidence of having politicians in many countries in their pockets) are also stakeholders in our ‘One World Approach’. Though they are not mentioned in the definition, they definitely have a stake in policy making, though their stake is not necessarily congruent with the core goals, and what this reveals is a messy mix of conflicting interests with many some stakeholders, complicated by a convergence of interests with other parties, along with excessive negative influence in the corridors of power.
Viewed this way it’s self-evident that this particular cadre of stakeholders need to be proactively controlled because their particular stake in ultimate outcomes relating to AMR control is incompatible with the wider stake of the ‘One Health Approach’ (though they would argue that it is at least compatible with the goal of feeding the world). But equally self-evidently, the policy makers themselves (almost certainly because of their own covert conflicts of interest) have not so far proved to be very good at their policy making whether it is by devious design or carelessness, and so have allowed both delays and simple loopholes to be exploited.
Of course, these activities should all be stopped by more effective public pressure, the very sort we encouraged in the previous blog, but unless they are highlighted (and media control does not necessarily help in this respect) this isn’t going to happen.
So the objective of raising ‘awareness’ during this WAAW week must include highlighting these sorts of challenges, because one goal is very simple: to successfully protect all important drugs, particularly antibiotics.
Critically important drugs
Drugs are divided for this purpose into three categories (‘critically important’, ‘highly important’ and ‘important’) and the official list of these is very long indeed. Obviously the ‘critically important’ ones are those that should be used least, with a ‘treat as little as possible but as much as necessary’ veterinary approach being vital. As far as possible prevention of AMR is key and one way this can be done is by rigorously legislating against husbandry practices that increase the risk of endemic disease in animal populations (that also match the One World approach). While fingers are often pointed towards better education being the solution among small scale farmers in countries like Bangladesh, it’s not difficult to realise that there's push-back coming from the industrial agricultural conglomerates and from the pharmaceutical suppliers, and no amount of education or encouragement will work on them. They MUST be legislatively controlled.
The aim must be this: for all of us (individuals, prescribing physicians, vets, farmers etc.) to use 'as little antibiotics as possible but as much as is necessary', but this needs far more active stewardship on the part of both global and national authorities – much more, for instance, than ‘celebrating’ a week in the year that most media appears to avoid reporting completely because there's not that much still to celebrate.
The national hotspots where these conflicts of interest are not hard to identify – particularly Brazil, China and India where there are huge agricultural industries feeding huge populations, and the U.S, of course, where industrial farming is practised at massive scale, but the same quality controls must be administered everywhere. One of the world’s biggest processors of factory farmed chickens, for instance is Thailand. As Sally Davies was quoted as saying in the second blog of this series “none of us are safe until we are all safe”, and with a deeper understanding of AMR it’s reasonable to suggest that the only thing about this that we can say is safe is this: that the current situation is very unsafe indeed.
We’re not being radical here in calling this out, incidentally. The UN’s FAO (Food and Agricultural Organisation) tells us all we need to know about this, and it is telling (underlinings are our own for emphasis): “Legislation is a key component in addressing the abuse, overuse, misuse and release of antimicrobials, and plays a vital role in regulating antimicrobial use (AMU) to minimize the risks of antimicrobial resistance (AMR). Legislation is essential for enhancing the sustainability of policy and technical objectives, and clarifying the roles and responsibilities of governments and other stakeholders in the fight against AMR. However, existing legislation relevant for AMU and AMR often fails to provide an appropriate regulatory answer to support public policies aimed at curbing AMR.”
There is plainly work to do still.
In the next blog we will discuss the pharma industry in more detail, in particular about its greed and its role in enabling a pipeline problem in respect of new antibiotics and the shenanigans it’s been using to free up this pipeline and make even more money at public expense in the process.