How systems change can slow antimicrobial resistance

For nearly a century, antimicrobial therapies have been the backbone of modern medicine. Since Alexander Fleming discovered penicillin in 1928, antibiotics have treated infections, transformed complex surgeries into routine procedures and safeguarded both animal welfare and farmers' productivity. That foundation is now threatened by antimicrobial resistance (AMR), which is rapidly becoming an urgent global economic and public health crisis.

Asia accounted for more than half the global 4.71 million AMR deaths in 2021 and deaths in the region alone due to AMR are projected to reach 5 million by 2050. Multiple organizations, including the World Health Organization (WHO), the UN and the Food and Agriculture Organization (FAO) have sounded the alarm, calling AMR an urgent threat to global health security.

The economic toll is equally staggering. The World Bank estimates that a high-AMR impact scenario could cost the global economy 3.8% of its annual GDP by 2050, with an annual shortfall of $3.4 trillion by 2030 – a financial impact more severe than the 2008 financial crisis. In Asia alone, AMR could cost up to $700 billion by 2050, consuming up to 1% of the continent's GDP and increasing healthcare expenditure by up to 10%.

AMR has now grown beyond a simple health problem into an unprecedented threat to health, economic and societal stability.

At its core, this crisis is fuelled by two interconnected forces. First, the human-accelerated evolution of bacteria and viruses across human medicine and animal agriculture, which makes current treatments less effective. Our misuse and overuse of antibiotics create conditions in which resistant bacteria thrive and spread. In human care, this occurs when antibiotics are taken for a viral illness, doses are skipped, or treatment is stopped early once symptoms subside.

This challenge is amplified in livestock farming, where antibiotics are routinely administered as prophylactic measures or to promote faster growth, particularly in poultry and pig production. This practice is especially salient in Southeast Asia, where livestock farming is a primary source of livelihood. The vast majority (74%) of the world's approximately 570 million small farms are located in South-East Asia, South Asia and China, collectively producing around 80% of locally consumed food. Many smallholder farms lack robust biosecurity measures, leading to routine antibiotic use for blanket prevention. These practices create conditions in which resistant germs are transmitted between animals, through the environment, and into the food chain to people, making infections harder to treat.

The second contributing factor is the severe antibiotics pipeline and access crisis. Developing a new antibiotic is difficult and expensive, typically costing around $1 billion and taking 10 to 15 years from discovery to market. Market conditions make it nearly impossible for companies to recoup these investments, leading to a critical absence of pharmacological innovation and a dwindling supply of effective antibiotics in what experts call a post-antibiotic era.

Revitalizing antimicrobial innovation requires concrete health preventive measures and sufficient “pull incentives” to foster R&D and innovation that contribute to building a more resilient public health system. Pull incentives can help break this cycle by rewarding successful R&D and creating a viable market for new treatments. They are crucial to attracting the private investment essential for breakthrough therapies.

For example, in the United Kingdom, the NHS subscription model charges a fixed annual fee for high-value antibiotics, regardless of usage, decoupling revenue from sales volume. In the US, the bipartisan PASTEUR Act would provide subscription contracts valued at roughly $750 million to $3 billion to spur R&D. If scaled and coordinated globally, these approaches can create a predictable market and sustained investment for effective antibiotics.

Antimicrobial stewardship and prevention in animal and human health must also be front and centre. The good news is that we already have proven preventative strategies to reduce antibiotic use without compromising animal health or food security. Vaccinating herds and flocks can prevent disease outbreaks, significantly reducing the need for antibiotics. When paired with improved farm hygiene, biosecurity, housing and nutrition, farmers can phase out prophylactic use (intended to prevent disease) and eliminate antibiotics as growth promoters.

Veterinarians play a pivotal role in guiding farmers toward responsible antibiotic use by prescribing only when necessary, selecting the right drug and dose and ensuring full treatment courses. They help to preserve the effectiveness of these vital medicines in a multimillion-dollar industry.

AMR does not respect boundaries between species or sectors. The One Health approach recognizes that human, animal and environmental health are interconnected. We stand at a pivotal moment where the threat of AMR is no longer distant – it is here, eroding the foundations of modern medicine. Combatting AMR requires coordinated action across all domains by expediting innovative economic models and through comprehensive strategies that integrate stewardship, prevention, surveillance and regulation. The time for decisive action is now.