Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy

Claas Kirchhelle^{1

2}, Paul Atkinson³, Alex Broom⁴, Komatra Chuengsatiansup⁵, Jorge Pinto Ferreira⁶, Nicolas Fortané⁷, Isabel Frost^{8

9}, Christoph Gradmann¹⁰, Stephen Hinchliffe¹¹, Steven J Hoffman¹², Javier Lezaun¹³, Susan Nayiga¹⁴, Kevin Outterson¹⁵, Scott H Podolsky¹⁶, Stephanie Raymond⁴, Adam P Roberts¹⁷, Andrew C Singer¹⁸, Anthony D So^{19

20}, Luechai Sringernyuang²¹, Elizabeth Tayler²², Susan Rogers Van Katwyk^{12

23}, Clare I R Chandler²⁴

Affiliations

¹ School of History, University College Dublin, Dublin, Ireland.
² Oxford Martin School, University of Oxford, Oxford, Oxfordshire, UK.
³ Department of Public Health and Policy/ Institute of Infection and Global Health, University of Liverpool, Liverpool, Merseyside, UK.
⁴ School of Social and Political Sciences, Faculty of Arts and Social Sciences, The University of Sydney, Sydney, New South Wales, Australia.
⁵ Princess Maha Chakri Sirindhorn Anthropology Center, Bangkok, Thailand.
⁶ Antimicrobial Resistance and Veterinary Products Department, World Organisation for Animal Health, Paris, Île-de-France, France.
⁷ Irisso, Paris-Dauphine University, PSL, INRAE, Paris, Île-de-France, France.
⁸ Center for Disease Dynamics Economics and Policy, Washington, DC, USA.
⁹ Department of Infectious Disease, Imperial College London, London, UK.
¹⁰ Institute for Health and Society, Dept. of Community Medicine and Global Health, University of Oslo, Oslo, Norway.
¹¹ Geography, College of Life and Environmental Sciences and Wellcome Centre for Cultures and Environments of Health, University of Exeter, Exeter, Devon, UK.
¹² Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada.
¹³ Institute for Science, Innovation and Society, School of Anthropology and Museum Ethnography, University of Oxford, Oxford, Oxfordshire, UK.
¹⁴ Infectious Diseases Research Collaboration, Kampala, Central Region, Uganda.
¹⁵ School of Law, Social Innovation on Drug Program, Boston University, Boston, Massachusetts, USA.
¹⁶ Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
¹⁷ Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK.
¹⁸ Pollution, UK Centre for Ecology & Hydrology, Wallingford, UK.
¹⁹ Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.
²⁰ Innovation + Design Enabling Access (IDEA) Initiative, ReAct - Action on Antibiotic Resistance, Baltimore, Maryland, USA.
²¹ Faculty of Social Sciences, Mahidol University, Salaya, Nakhon Pathom, Thailand.
²² Global Coordination and Partnerships, AMR Division, World Health Organisation, Geneva, Switzerland.
²³ Global Strategy Lab, York University, Toronto, Ontario, Canada.
²⁴ Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK clare.chandler@lshtm.ac.uk.

PMID: 32967980
PMCID: PMC7513567
DOI: 10.1136/bmjgh-2020-003091

Review

Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy

Claas Kirchhelle et al. BMJ Glob Health. 2020 Sep.

. 2020 Sep;5(9):e003091.

doi: 10.1136/bmjgh-2020-003091.

Authors

Affiliations

¹ School of History, University College Dublin, Dublin, Ireland.
² Oxford Martin School, University of Oxford, Oxford, Oxfordshire, UK.
³ Department of Public Health and Policy/ Institute of Infection and Global Health, University of Liverpool, Liverpool, Merseyside, UK.
⁴ School of Social and Political Sciences, Faculty of Arts and Social Sciences, The University of Sydney, Sydney, New South Wales, Australia.
⁵ Princess Maha Chakri Sirindhorn Anthropology Center, Bangkok, Thailand.
⁶ Antimicrobial Resistance and Veterinary Products Department, World Organisation for Animal Health, Paris, Île-de-France, France.
⁷ Irisso, Paris-Dauphine University, PSL, INRAE, Paris, Île-de-France, France.
⁸ Center for Disease Dynamics Economics and Policy, Washington, DC, USA.
⁹ Department of Infectious Disease, Imperial College London, London, UK.
¹⁰ Institute for Health and Society, Dept. of Community Medicine and Global Health, University of Oslo, Oslo, Norway.
¹¹ Geography, College of Life and Environmental Sciences and Wellcome Centre for Cultures and Environments of Health, University of Exeter, Exeter, Devon, UK.
¹² Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada.
¹³ Institute for Science, Innovation and Society, School of Anthropology and Museum Ethnography, University of Oxford, Oxford, Oxfordshire, UK.
¹⁴ Infectious Diseases Research Collaboration, Kampala, Central Region, Uganda.
¹⁵ School of Law, Social Innovation on Drug Program, Boston University, Boston, Massachusetts, USA.
¹⁶ Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
¹⁷ Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK.
¹⁸ Pollution, UK Centre for Ecology & Hydrology, Wallingford, UK.
¹⁹ Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.
²⁰ Innovation + Design Enabling Access (IDEA) Initiative, ReAct - Action on Antibiotic Resistance, Baltimore, Maryland, USA.
²¹ Faculty of Social Sciences, Mahidol University, Salaya, Nakhon Pathom, Thailand.
²² Global Coordination and Partnerships, AMR Division, World Health Organisation, Geneva, Switzerland.
²³ Global Strategy Lab, York University, Toronto, Ontario, Canada.
²⁴ Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK clare.chandler@lshtm.ac.uk.

PMID: 32967980
PMCID: PMC7513567
DOI: 10.1136/bmjgh-2020-003091

Abstract

There is increasing concern globally about the enormity of the threats posed by antimicrobial resistance (AMR) to human, animal, plant and environmental health. A proliferation of international, national and institutional reports on the problems posed by AMR and the need for antibiotic stewardship have galvanised attention on the global stage. However, the AMR community increasingly laments a lack of action, often identified as an 'implementation gap'. At a policy level, the design of internationally salient solutions that are able to address AMR's interconnected biological and social (historical, political, economic and cultural) dimensions is not straightforward. This multidisciplinary paper responds by asking two basic questions: (A) Is a universal approach to AMR policy and antibiotic stewardship possible? (B) If yes, what hallmarks characterise 'good' antibiotic policy? Our multistage analysis revealed four central challenges facing current international antibiotic policy: metrics, prioritisation, implementation and inequality. In response to this diagnosis, we propose three hallmarks that can support robust international antibiotic policy. Emerging hallmarks for good antibiotic policies are: Structural, Equitable and Tracked. We describe these hallmarks and propose their consideration should aid the design and evaluation of international antibiotic policies with maximal benefit at both local and international scales.

Keywords: diseases; disorders; health policies and all other topics; infections; injuries; public health.

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Conflict of interest statement

Competing interests: SH is Scientific Director of CIHR’s Institute of Population and Public Health and CIHR’s Scientific Co-Lead for Antimicrobial Resistance. He is Director of the WHO Collaborating Centre on Global Governance of Antimicrobial Resistance. KO in principal investigator of CARB-X, a project at Boston University (my employer), funded by three governments (US, UK and Germany) and two charitable foundations (Wellcome Trust and the Bill & Melinda Gates Foundation). CARB-X is a non-profit, making grants for preclinical antibacterial research. I do not view this as a conflict, but disclose in an abundance of caution. APR is the co-ordinator of the JPIAMR funded Network NEAR-AMR. ADS reports grants from ReAct-Action on Antibiotic Resistance and from Open Society Foundation during the conduct of the study. He served as Co-Convener of the UN Interagency Coordination Group on Antimicrobial Resistance (2018–2019), as a member of the Expert Commission on Addressing the Livestock Contribution to the Antibiotic Resistance Crisis (2016–2017), as a commissioned author to the UK Commission on AMR on 'A Framework for Costing the Lowering of Antimicrobial Use in Food Animal Production' (2016), as Head of the Secretariat of the Antibiotic Resistance Coalition, and as a Member of the Working Group on Antibiotic Resistance for the President’s Council of Advisors on Science and Technology (2013–2014).

Figures

**Figure 1**
Interlinked hallmarks of successful antibiotic policy-making.

**Figure 2**
An ideal-type set of interventions for international food production. Ideal-type example of how using reflective policy-making in accordance with SET hallmarks could inform the design of equitable trade arrangements to: satisfy high income country demand for affordable sustainably produced protein; fulfil low income country calls for structural healthcare and surveillance capacity building and market access; encourage value driven. One health stewardship with multifactorial metrics integrating data on animal health with low-cost environmental sentinel monitoring for antimicrobial residues as a proxy for regional antimicrobial use (AMU). AMR, antimicrobial resistance; SET, Structural, Equitable and Tracked.

See this image and copyright information in PMC

References

1. Chandler CIR, Hutchinson E, Hutchison C. Addressing antimicrobial resistance through social theory. An Anthropologically oriented report. London: London School of Hygiene & Tropical Medicine, 2016.
1. Hoffman SJ, Caleo GM, Daulaire N, et al. Strategies for achieving global collective action on antimicrobial resistance. Bull World Health Organ 2015;93:867–76. 10.2471/BLT.15.153171 - DOI - PMC - PubMed
1. Hollis A, Maybarduk P. Antibiotic resistance is a tragedy of the commons that necessitates global cooperation. J Law Med Ethics 2015;43 Suppl 3:33–7. 10.1111/jlme.12272 - DOI - PubMed
1. Cars O, Högberg LD, Murray M, et al. Meeting the challenge of antibiotic resistance. BMJ 2008;337:a1438. 10.1136/bmj.a1438 - DOI - PubMed
1. Laxminarayan R, Malani A. Extending the cure: policy responses to the growing threat of antibiotic resistance: Earthscan, 2007.

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Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy

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Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy

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Conflict of interest statement

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