Building ‘One Health’ momentum for people, animals and the environment across the Global South

One after the other, scientific presentations made at the highest levels are moving the needle on ‘whole of health’ approaches by, in and for developing countries

UK Parliament (House of Commons and House of Lords), 28 Jun 2023, London

Later that month, my colleague Arshnee Moodley and I made a presentation to members of the UK Parliament on One Health and Antimicrobial Resistance. A project funded by the Foundation to Prevent Antibiotic Resistance had organized small group sessions between parliamentarians and academics with the aim of giving the members of parliament and peers advice on their areas of expertise and how they intersect with antimicrobial resistance.

I began my presentation by introducing CGIAR, to which my centre, ILRI, belongs.

CGIAR has been conducting agricultural research for development for the past half century. It hosts 15 research centres, is home to some 10,000 staff representing 135 nationalities, partners more than 3,000 organizations and works in more than 100 countries.

Based in Nairobi, Kenya, I co-lead ILRI’s Animal and Human Health Program. I also lead the CGIAR Initiative on One Health, one of CGIAR’s 33 global research initiatives. This initiative is using One Health approaches to tackle zoonotic diseases, which are transmitted from animals to people; foodborne diseases, which are caused by ingesting foods contaminated with pathogenic bacteria, viruses or parasites; and diseases caused by antibiotic-resistant infections.

For many years, UK research institutions, councils, health and development initiatives and donor agencies have led the way in advancing research on each of these topics. And the UK has generously funded ILRI research on antimicrobial resistance through the Fleming Fund, the Foreign Commonwealth & Development Office (FCDO), UK Aid and UK Research and Innovation.

One Health challenges remain at the top of the UK’s policy agenda because of the UK’s deep expertise in the relevant biosciences and because the topics present such huge global public health risks.

Zoonotic diseases, for example, make up 70–80% of all infectious diseases of humans and, as the COVID-19 pandemic has so vividly demonstrated, can cost many trillions of dollars and untold suffering globally.

Foodborne diseases remain a huge and persistent health problem in poor countries, where their burden is as large as that of malaria, tuberculosis or HIV/AIDS.

Antimicrobial-resistant infections are becoming increasingly common, making antibiotic drugs less and less effective against diseases such as pneumonia, tuberculosis, gonorrhoea and salmonellosis and making antibiotic resistance one of the biggest growing threats to global health.

There are several reasons for paying special attention to these three kinds of diseases in countries and regions of the developing world.

First, livestock and livestock systems play roles in all three of these kinds of diseases and the livestock sector is growing in many low- and middle-income countries with rising demand there for beef, pork, poultry and milk products. If that growth is not managed well, the risks these diseases pose could grow as well.

A second reason for paying special attention to countries of the Global South is that these are where most of the world’s livestock are raised, often in close proximity to human populations. Thus, some of the global ‘hotspots’ of emerging and re-emerging zoonotic diseases, which can ‘spill over’ from wild and domesticated animals to people, occur here. As I noted earlier, this is also where endemic zoonoses and foodborne diseases take their heaviest tolls. Finally, the fast-growing livestock sectors of poorer countries are using more and more antimicrobial drugs to keep their livestock healthy and to grow them faster, which encourages the development of antibiotic-resistant pathogens.

As I explained to the parliamentarians, the four so-called ‘Quadripartite’ organizations—the Food and Agriculture Organization of the United Nations (FAO), United Nations Environment Programme (UNEP), World Health Organization (WHO) and World Organisation for Animal Health (WOAH)—are working together to advocate and support taking a One Health approach to tackling these health problems. One Health’s integrated, unifying approach aims to sustainably balance and optimize the health of people, animals and ecosystems.

The CGIAR Initiative on One Health unites the work of four CGIAR centres—the International Food Policy Research Institute (IFPRI), the International Livestock Research Institute (ILRI), the International Water Management Institute (IWMI) and the World Fish Center (WorldFish)—as well as that of the Swiss Center for Scientific Research (CSRS), the EcoHealth Alliance and the University of Liverpool.

Members of the CGIAR One Health Initiative are working with the Quadripartite and others, such as the CGIAR AMR Hub, OHRECA, COHESA and One Health in Southeast Asia initiatives, to accomplish the following 5 main goals.

1 reduce zoonotic diseases

Reduce the emergence and transmission of emerging, re-emerging and endemic zoonotic diseases that occur at wildlife-livestock-people interfaces.

2 reduce foodborne diseases

Reduce foodborne diseases by enabling small-scale food sellers to provide safe food and providing them with incentives for doing so.

3 reduce antimicrobial resistance

Reduce the emergence and spread of zoonotic pathogens that have developed resistance to antibiotics and other antimicrobial drugs.

4 reduce waterborne diseases

Reduce infectious disease risks through improved water management.

5 reduce behaviour compromising one health

Reduce behaviour that compromises One Health by understanding the economic and governance constraints to—and incentives for—implementing One Health approaches.

I reminded my parliamentary audience that use of antimicrobial drugs remains essential in developing as well as developed countries. These drugs protect human health and welfare and food safety and security; they protect animal health, welfare and productivity; and they protect environment health, particularly that of water and soil quality, climate change mitigation and sustainable crop production.

While recognizing the importance of preserving the efficacy of antimicrobials through their judicious use (drug resistance has dramatically increased the costs of fighting TB and malaria, slowed gains against childhood dysentery and pneumonia, and threatens effective treatments for people living with HIV/AIDS), we also need to be mindful of the potential large and unintended harms of reducing antimicrobial use in low- and middle-income countries, which are facing so many socio-economic, food, climate and other challenges.

It’s a balancing act. No amount of regulations or training will ensure judicious use of these drugs on their own; poor countries and communities will also need proper incentives. 

The CGIAR Antimicrobial Resistance Hub (AMR Hub), led by ILRI’s Arshneee Moodley, was launched in 2019 to elucidate the balancing act needed to help lower income countries mitigate their agriculturally associated drug resistance risks. This work includes looking at what drives antimicrobial use in these countries, the quality of the drugs and how they are being accessed; the prevalence and transmission of drug resistance on farms and in foods; optimal interventions for reducing antimicrobial use and resistance; policy gaps, challenges and opportunities related to antimicrobial use in developing countries; and what lab, field and policy capacities need to be strengthened in these countries to ensure rational use of antibiotics and other antimicrobial medicines.

This CGIAR AMR Hub is based at ILRI’s headquarters, in Nairobi, Kenya, where most of ILRI’s advanced biosciences laboratories are located, and is run jointly by ILRI, IFPRI, IWMI and WorldFish. The Hub work relies utterly on productive partnerships—those among the CGIAR centres and their national and other partners as well as among the diverse disciplines and sectors—from medical to veterinary to ecological—that are necessary for One Health work to work.

Livestock producers use antimicrobial agents to meet different objectives—from preventing outbreaks of infectious diseases to treating sick animals to preventing disease spread to increasing livestock growth rates and feed efficiencies.

Antimicrobial use in animal husbandry is highest in Asia, followed by the Americas and Europe, and is lowest in Africa.

Among our learnings from six years of CGIAR research on antimicrobial use and resistance in the Global South are that there exists little knowledge of pathogen resistance among both antimicrobial users and prescribers; there are few tools and resources available to better manage antimicrobial use, which encourages imprudent practices; drug resistance occurs both on farms and in food products; policymakers lack awareness of the drug resistance problem and also lack relevant data; there are bottlenecks in antimicrobial drug supply chains; and there is limited laboratory capacity to diagnose drug resistance.

While global leaders are calling for significant reductions (by 30–50% from current levels) in the use of antimicrobial drugs in the world’s food systems, the (big) question remains as to how to effect this fairly as well as successfully.

Europe appears very much on the right track in reducing antimicrobial use and, therefore, antimicrobial resistance. Raising salmon in cages used to be a problem—the biggest producer is Norway, followed by Chile—but while antimicrobial use remains high in Chile, Norway has managed to almost eliminate antimicrobials while at the same time increasing production. So overuse of antimicrobials in aquaculture appears to be a solvable problem. With surveillance for antimicrobial resistance and regulatory enforcement, Canada and some other high-income countries have managed to make more appropriate use of these drugs.

In low- and middle-income countries, different strategies are needed to ensure more appropriate drug use, and these strategies also differ when used to reduce antibiotic use and to reduce transmission of antibiotic-resistant pathogens. Global and national actions plans are also needed to build the enabling environments needed for fair and rational drug use.

To do a better job, we also need to understand the cost-benefits of any intervention and the incentives (and disincentives) for making any changes. We need to determine who should change their behaviour and what resources they have to for doing so.

To address antimicrobial resistance in the livestock sector of lower income countries, we’ll have to jump on strategic opportunities to improve the entire livestock-based ecosystem as well as nudge livestock producers toward desired behaviours that move them, for example, from over-reliance on antimicrobial drugs to implementing greater biosecurity practices and regular animal vaccinations to adopting optimal animal husbandry practices.

We’ll also have to pay much greater attention to gender equity.

With two-thirds of the 600 million poor farmers practising mixed crop-and-livestock agriculture being women, for interventions to reduce antimicrobial resistance to be effective, we have to empower women livestock farmers.

Gender-blind interventions won’t work; inadvertently, they can actually cause women to lose their livestock businesses altogether.

Our years of learnings tell us that our CGIAR AMR Hub research needs to advance along all five fronts

1) The Hub needs to quantify on-farm antibiotic consumption, determine the drivers of antibiotic use (e.g. to prevent or treat infectious diseases), and to map veterinary antibiotic supply chains.

2) It needs to elucidate kinds and levels of antimicrobial resistance in animal pathogens and to understand the impacts of drug use and resistance on the environment, on climate change and at the livestock-wildlife interface.

3) Hub research needs to determine the costs and benefits of farm-level interventions to control drug use and resistance, to understand what triggers desired behaviour change and what incentives are needed to encourage those changes.

4) It needs to map policies and regulations that impinge on antimicrobial use, to investigate antibiotic supply chains, to determine the quality of antibiotics sold to customers, and to assess the gender responsiveness and impacts of antimicrobial-focused projects.

5) And the Hub needs to help raise capacity in diagnosing antimicrobial resistance, to conduct drug resistance surveillance work and to mentor early-career scientists in this and related One Health work.

That a tall order. But with adequate funding, ILRI and CGIAR are uniquely positioned to fulfil these objectives.