In the wake of COVID-19, the World Health Organization established an Intergovernmental Negotiating Body to negotiate a new instrument for pandemic prevention, preparedness, and response. This special issue of the Journal of Law, Medicine & Ethics brings together multidisciplinary scholarship to address the question of whether antimicrobial resistance should be included in this new instrument. Drawing from disciplines including law, anthropology, history, public health, public policy, economics, and veterinary medicine, this special issue explores the inclusion of AMR within the Pandemic Instrument from three perspectives: first, through the lens of global AMR governance, second, from the perspective of technical governance challenges and opportunities affecting the global ability to address AMR and future pandemics, and third, from the perspective of pandemic instrument mechanisms for strengthening global AMR governance. Each paper makes a concrete recommendation with respect to the importance of including AMR within the scope of the pandemic instrument

Outterson, Kevin

Rogers Van Katwyk, Susan

Scholarly Commons at Boston University School of Law

Boston University School of Law Scholarly Commons at Boston University School of Law Faculty Scholarship Winter 2022 INTRODUCTION: AMR Belongs in the Pandemic Instrument Susan Rogers Van Katwyk Kevin Outterson Follow this and additional works at: https://scholarship.law.bu.edu/faculty_scholarship  Part of the Health Law and Policy Commons 6 journal of law, medicine & ethics The Journal of Law, Medicine & Ethics, 50 S2 (2022): 6-8. © 2023 The Author(s)DOI: https://doi.org/10.1017/jme.2022.73INTRODUCTION:  AMR Belongs in the Pandemic InstrumentSusan Rogers Van Katwyk1 and Kevin Outterson2 1: YORK UNIVERSITY IN TORONTO, ONTARIO, CANADA, 2: BOSTON UNIVERSITY, BOSTON, MA, USA. This special issue of the Journal of Law, Medi-cine & Ethics brings together multidisciplinary scholarship that addresses the question of whether antimicrobial resistance should be included in a new global health in a new global health treaty on pandemic prevention, preparedness, and response.In the wake of COVID-19, the WHO established an Intergovernmental Negotiating Body to negotiate a new instrument for pandemic prevention, prepared-ness, and response. Despite initial calls for a broad scope — recognizing that pandemics and other major health emergencies require One Health international cooperation1 — in the working draft of the text for INB2 in July 2022, pandemic preparedness efforts are limited to emerging viral diseases such as COVID-19, but does not address other bacterial and fungal pandemic threats including antimicrobial resistance (AMR).AMR is accurately described as a serious threat to global health and wellbeing, with 1.27 million deaths attributable to bacterial AMR and a further 3.68 mil-lion deaths associated with bacterial AMR in 2019, a “health problem whose magnitude is at least as large as major diseases such as HIV and malaria, and potentially much larger.”2 This burden falls dispropor-tionately on low- and middle-income regions of the world, and especially children under five, threaten-ing achievement of several Sustainable Development Goals.3 AMR reflects social gradients, such as poverty and the lack of access to infection prevention and aggravates inequalities by disproportionately falling upon the poorest amongst us.4 AMR is also an important health issue in high-income countries — one that has been exacerbated by COVID-19.5 The Centers for Disease Control and Prevention estimated more than 35,000 died in the Keywords: Antimicrobial Resistance, Pandemic Instrument, One Health, Global Health Law.Abstract: In the wake of COVID-19, the World Health Organization established an Intergov-ernmental Negotiating Body to negotiate a new instrument for pandemic prevention, prepared-ness, and response. This special issue of the Jour-nal of Law, Medicine & Ethics brings together multidisciplinary scholarship to address the ques-tion of whether antimicrobial resistance should be included in this new instrument. Drawing from disciplines including law, anthropology, history, public health, public policy, economics, and vet-erinary medicine, this special issue explores the inclusion of AMR within the Pandemic Instru-ment from three perspectives: first, through the lens of global AMR governance, second, from the perspective of technical governance challenges and opportunities affecting the global ability to address AMR and future pandemics, and third, from the perspective of pandemic instrument mechanisms for strengthening global AMR gov-ernance. Each paper makes a concrete recom-mendation with respect to the importance of including AMR within the scope of the pandemic instrument. Susan Rogers Van Katwyk, Ph.D., is the Research Director of the Global Strategy Lab’s Global Antimicrobial Resistance Program at York University in Toronto, Ontario, Canada.   Kevin Outterson, J.D., LL.M., is a Professor of Law at Bos-ton University in Boston, MA, USA. https://doi.org/10.1017/jme.2022.73 Published online by Cambridge University PressRogers Van Katwyk and Outtersonaddressing antimicrobial resistance through the proposed pandemic instrument • winter 2022 7The Journal of Law, Medicine & Ethics, 50 S2 (2022): 6-8. © 2023 The Author(s)United States from antibiotic-resistant infections in 2017,6 while AMR deaths in Europe more than dou-bled from 2007 to 2015, reaching 33,110 deaths.7 Resistance is a natural evolutionary response to the presence of antimicrobial drugs driving selec-tion in the ecosystem.8 Humans have intervened by introducing vast quantities of antimicrobial drugs into human, industrial, and agricultural systems, and hence into the global environment,9 necessitat-ing a One Health approach. But instead of holistic approaches, global health initiatives have frequently been organized in silos driven by biological taxon-omy (and the availability of funding streams). If the pandemic instrument is limited to viral diseases and ignores other microbial threats like bacteria, another silo will have been constructed, missing the opportu-nity for important cross-linkages between bacterial and viral diseases such as WASH, surveillance, equi-table access, food safety and security, health system strengthening, infection prevention, animal welfare, and priority setting (Figure 1).10Given the many positive co-benefits described in Figure 1 by the Global Leaders Group on AMR, a compelling case must be articulated before excluding bacterial infections, in human history have included pandemics such as the plague. In addition to acknowl-edging the pandemic potential of bacterial infections, it is crucial to recognize that (1) antibiotics are an essential resource for responding to pandemic emer-gencies that must be protected, and (2) that the use of Figure 1Overlap in strategies and co-benefits for AMR and pandemic prevention, preparedness and response. Global Leaders Group Position Statement,  April 2022.11https://doi.org/10.1017/jme.2022.73 Published online by Cambridge University Press8 journal of law, medicine & ethicsJLME SUPPLEMENTThe Journal of Law, Medicine & Ethics, 50 S2 (2022): 6-8. © 2023 The Author(s)antibiotics during pandemic emergencies exacerbates the AMR threat.  While antibiotics saved the lives of many who contracted secondary bacterial infections during the COVID-19 pandemic, their use also pre-cipitated a 15% increase in both resistant hospital-onset infections and deaths during the first year of the COVID-19 pandemic in the United States.12 Develop-ing a treaty focused on pandemic preparedness and response that neglects to prepare or respond for the growing challenge of resistance is ill-advised. Instead of looking to the full range of human behav-iors for solutions, most of the COVID-19 research funding has gone to creating new medical counter-measures. AMR research has followed a similar pat-tern. For such problems rooted in both microbiol-ogy and complex human behavior, multidisciplinary approaches seem advisable. The Pandemic Instru-ment offers an opportunity to address this imbal-ance through a suite of new, and synergistic, gover-nance strategies that go beyond funding for medical countermeasures. We are pleased to offer this peer-reviewed selection of papers exploring the advisability of including AMR within the pandemic instrument, drawing from disci-plines such as law, anthropology, history, public health, public policy, economics, and veterinary medicine. These papers explore the inclusion of AMR within the pandemic instrument from three perspectives: first, through the lens of global AMR governance, second, from the perspective of technical governance chal-lenges and opportunities affecting the global ability to address AMR and future pandemics, and third, from the perspective of pandemic instrument mechanisms for strengthening global AMR governance. Each paper makes a concrete recommendation with respect to the importance of including AMR within the scope of the pandemic instrument. AcknowledgementsThe editors wish to thank Erin Wolter (Boston University Law, 2024) and Fiona Emdin (Dahdaleh Research Fellow at the Global Strategy Lab) as well as the editorial team at ASLME for their sup-porting bringing together this special issue.NoteThis work was supported by the Canadian Institutes of Health Research [#149542], the Social Sciences & Humanities Research Council [#895-2022-1015], and the Wellcome Trust [222422/Z/21/Z]. The funding bodies were not involved in the study design, data collection, analysis, interpretation or writing.References1. WHO, “COVID-19 Shows Why United Action Is Needed for More Robust International Health Architecture,” available at <https://www.who.int/news-room/commentaries/detail/op-ed---covid-19-shows-why-united-action-is-needed-for-more-robust-international-health-architecture> (last visited September 29, 2022).2. C.J. Murray, K.S. Ikuta, F. Sharara, L. Swetschinski, G. Robles Aguilar, A. Gray, et al., “Global Burden of Bacterial Antimi-crobial Resistance in 2019: A Systematic Analysis,” The Lancet 399, no. 10325 (2022): 629-655. 3. WHO, “Antimicrobial Resistance and the United Nations Sus-tainable Development Cooperation Framework: Guidance for United Nations Country Teams,” 2021. 4. L.A. Wilson, S. Rogers Van Katwyk, P. Fafard, A.M. Viens, and S.J. Hoffman, “Lessons Learned from COVID-19 for the Post-Antibiotic Future,” Global Health 16, no. 1 (2020): 94. 5. CDC, National Center for Emerging and Zoonotic Infectious Diseases, COVID-19: U.S. Impact on Antimicrobial Resistance, Special Report 2022, available at <https://stacks.cdc.gov/view/cdc/117915> (last visited September 29, 2022).6. CDC, US Department of Health and Human Services, “Antibi-otic Resistance Threats in the United States,” 2019. 7. P. Venkatesan, “2022 Post-ECCMID Day on Antimicrobial Resistance,” The Lancet Microbe 3, no. 8 (2022): e565-6. 8. F. Baquero, C. Alvarez-Ortega, and J.L. Martinez, “Ecol-ogy and Evolution of Antibiotic Resistance,” Environmental Microbiology Reports 1, no. 6 (2009): 469-476. 9. S. Hernando-Amado, T.M. Coque, F. Baquero, and J.L. Mar-tínez, “Defining and Combating Antibiotic Resistance from One Health and Global Health Perspectives,” Nature Microbi-ology 4, no. 10 (2019): 1432-1442. 10. Global Leaders Group on Antimicrobial Resistance, “Why AMR Must Be a Substantive Element of the Interna-tional Instrument on Pandemic Prevention, Preparedness and Response,” available at <https://www.amrleaders.org/resources/why-amr-must-be-a-substantive-element-of-the-international-instrument-on-pandemic-prevention-prepared-ness-and-response> (last visited September 29, 2022).11. Id.12. See CDC, supra note 5.https://doi.org/10.1017/jme.2022.73 Published online by Cambridge University Press

INTRODUCTION: AMR Belongs in the Pandemic Instrument

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INTRODUCTION: AMR Belongs in the Pandemic Instrument

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