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Pitchforth, E

Thornber, K

JAC-Antimicrobial Resistance

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Communicating antimicrobial resistance: the need to go beyondhuman healthKelly Thornber1* and Emma Pitchforth21Department of Biosciences, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK; 2College of Medicine and Health, University ofExeter, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU, UK*Corresponding author. E-mail: k.thornber@exeter.ac.ukDespite significant resource mobilization to address antimicrobialresistance (AMR), a persistent ‘action gap’ remains between AMRgovernance and the realization of societal change. Across inter-national and national governance networks, AMR is widely recog-nized as an issue that goes beyond human health, requiringconsiderable and urgent attention from all sectors of society. Incontrast, AMR awareness campaigns remain predominantlyfocused on framing AMR as a human health issue, with messagestargeting individualistic antimicrobial consumption. In this article,we make the case that AMR awareness campaigns should framethe issue as one that goes beyond human health, in order to en-gage a greater number and broader array of stakeholders fromacross society. We argue that this could support efforts to reducethe AMR action gap, by making the issue more relevant to a widerrange of stakeholders, expanding the sphere of responsibility andmoving the focus from individualistic to societal-wide change.The COVID-19 pandemic has demonstrated not only the far-reaching impact of a single untreatable infectious pathogen butalso the scope for rapid, societal-wide change in response to sucha threat. Antimicrobial resistance (AMR) has received considerableinternational attention and resources, and potentially poses amuch greater long-term clinical, economic, social and environ-mental threat than COVID-19,1–3 yet societal-wide engagementand action on the issue is proving difficult to realize.4,5 At the heartof the response to COVID-19 has been effective communicationbetween stakeholders from different sectors, with problems ofnoncompliance blamed on poor clarity and consistency ofmessaging, even when backed by law.6 The UK Government’s in-dependent review on AMR recommended a massive global aware-ness campaign estimated at 40–100 million USD per year,3 andeffective AMR communication is a cornerstone of the global AMRaction plan,7 however studies continue to show relatively lowlevels of AMR awareness across the globe, with common misun-derstandings and a sense among the public that AMR is an issuebeyond their control.8–10 The Interagency Co-ordination Group(IACG) on AMR have identified the need to go beyond humanhealth when communicating AMR, recommending it is framed inthe context of achieving wider societal goals such as food securityand sustainable development in order to engage publics outsidethe clinic and overcome the AMR public–policy ‘action gap’.4,11Accordingly, the holistic One Health approach has become adominant discourse within international AMR policy documentsand national AMR action plans, despite criticism over its inherentanthropocentricity.11–15 In contrast, the majority of public aware-ness campaigns to date, and the recent guidelines developed tosupport these, have remained focused on framing AMR as ahuman health issue, with messages largely targeting individualclinical encounters and antibiotic misuse rather than the wider so-cietal action that is required to address both antibiotic misuse andAMR transmission.8,16,17 For example, the UK’s ongoing ‘KeepAntibiotics Working’ campaign specifically targets individual anti-biotic users, and frames AMR as a human health issue that risks ‘amore severe or longer illness’.18 Guidelines on the responsible useof antibiotics in UK farm animals frame AMR as an issue that couldaffect both human and animal health, but defer responsibilityfrom antimicrobial use in animals, repeatedly stating that ‘Theconsensus amongst experts is that the main cause of antibioticresistance in human pathogens is the overuse and/or inappropri-ate use of antibiotics in human medicine’.19 Thus, despite theacknowledged importance of inclusive framing to engage a wideraudience, this is not how AMR is typically being communicated tothe public. We draw upon evidence to make the case that thisneeds to change.Widespread public support has been shown to be key for bothbringing policy development to the fore as well as for successfulimplementation,8 and we take the assumption that effective com-munication plays an important role in mobilizing the coordinatedsupport and effort required across sectors and disciplines toachieve this.20,21 How a message is framed is key to clearly defin-ing the problem, who is accountable, who will be impacted and,importantly, the solutions.22 Framing AMR as an issue that goesbeyond human health would expand its defined impacts to incorp-orate the significant risks that AMR transmission and the inappro-priate use of antimicrobial compounds pose to global foodsecurity, animal welfare and the natural environment. In turn, thiswould expand the size of the population and the breadth of stake-holders who consider the issue to have relevance to their lives,increasing the number of people and organizations who may takeVC The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.1 of 3JAC Antimicrob Resistdoi:10.1093/jacamr/dlab096JAC-AntimicrobialResistanceaction to address it. More inclusive framing of AMR would also val-idate the use of animals and the environment to engage the publicon the issue; these are two emotive subjects that could help togain public support, and could be used to expand the impacts ofvisual imagery, which is particularly emotive yet traditionally chal-lenging for AMR awareness campaigns due to the microscopicscale at which AMR operates.8,23 The use of antimicrobials in farmanimals and the environmental impacts of pharmaceutical pollu-tants are current issues within the public domain and may bemore immediate to some publics than resistant infections;24,25incorporating these into AMR communications may therefore helpto overcome our common tendencies towards temporal discount-ing and proximization, whereby future and more distant risks areperceived with reduced severity.20,26 More inclusive definitions ofthe causes and solutions to the issue would also widen engage-ment by going beyond ‘antimicrobial misuse’ and bringing greaterattention to the myriad of societal-wide factors that are increas-ingly established as the major forces driving global AMR.27–29 Byframing AMR as an issue that goes beyond human health, the solu-tions defined, and responsibility for their uptake, would reach fur-ther than the individual antimicrobial consumer, who often haslimited capacity to act.20,30 This would extend culpability to sectorsof society that may seem remote from modern medicine butnevertheless contribute towards providing an environment inwhich AMR can emerge and disseminate, such as the food andmanufacturing industries.31The international AMR community has called for more researchinto optimizing AMR communications for local contexts, to improveunderstanding of localized AMR risk in order to evaluate/prioritizeinterventions and tailor solutions.4,8,10,16,32,33 To this end, framingAMR as an issue that goes beyond human health would enable abroader range of messages to be targeted to more diverseaudiences, and importantly help to engage those for whom therisk of their actions undermining modern medicine is not a prior-ity, for example, stakeholders in food production industries inlow- and middle-income countries.30 Future AMR awarenessplanning could take lessons from COVID-19 and climate changeresearch into strategic narratives to address policy–society ac-tion gaps, which have highlighted the importance of engagingall stakeholders across society to iteratively co-create a narra-tive through constructive dialogue.6,34 As the AMR GlobalLeaders Group continues to provide leadership for AMR commu-nication strategies, research into their practical implementationshould engage with those for whom these strategic narrativesare targeted. This needs to go beyond human health, to includethe plethora of actors from across the breadth of society whoseactions are responsible for the causes, solutions, and fate,of AMR.AcknowledgementsWe thank Professor Steve Hinchliffe for useful discussions and generalinterdisciplinary support.FundingThis work was supported by funding to the authors as follows. K.T. was sup-ported by a University of Exeter internal GCRF Translation Award (‘Promotingprudent pharmaceutical usage in Bangladesh aquaculture, PI: Thornber’),funded by the EPSRC (‘University of Exeter GCRF Global Research TranslationAward: Sustainable Solutions to Food Security Challenges’, ref: EP/T015268/1), a BBSRC/NERC/GCRF grant (‘Improving hatchery biosecurity for a sustain-able shrimp industry in Bangladesh’, ref: BB/T012579/1, PI: Tyler) and fund-ing from the University of Exeter Provost Fund (‘Building a University-WideAntimicrobial Resistance Research Community’, PI: Gaze). E.P. is currently co-applicant on two AMR-related projects funded through GCRF (‘One HealthDrivers of AMR in Rural Thailand’ PI: Avison) and BBSRC/NERC-CONICET (‘Aconceptual framework to improve understanding of AMR in livestock sys-tems for translation into policy and practice’; PI: Gaze & Petroni).Transparency declarationsNone to declare.Data access statementThis is a viewpoint article, and therefore all data underlying this work arecited in the references.References1 Charlton E. The Looming Health Catastrophe That Could Be More Deadlythan COVID-19. World Economic Forum, 2020. https://www.weforum.org/agenda/2020/11/superbugs-health-risk-antimicrobial-resistance/.2 The Guardian. ‘Superbugs’ a Far Greater Risk Than Covid in Pacific, ScientistWarns, 2020. https://www.theguardian.com/world/2020/sep/10/superbugs-a-far-greater-risk-than-covid-in-pacific-scientist-warns.3 O’Neill J. Tackling Drug-Resistant Infections Globally: Final Report andRecommendations. 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Communicating antimicrobial resistance: the need to go beyond human health

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Communicating antimicrobial resistance: the need to go beyond human health

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