Irresponsible use of antimicrobials, including antibiotics, is accelerating the rise of ‘superbugs’. These superbugs are causing infections that were once easily treatable by antimicrobials but are now becoming increasingly difficult to treat and, in some cases, turning life-threatening. Unnecessary use of antimicrobials coupled with poor infection prevention measures and lack of new antimicrobials has resulted in a full-blown global health crisis of Antimicrobial Resistance (AMR). The climate crisis is also affecting patterns of infectious diseases which may lead to an increase in the use of antimicrobial drugs and a rise in AMR. 

While the problem of AMR has reached a tipping point in India, there are countless and yet, often unheard of superheroes – in research labs, hospitals, and on the ground, among communities – who are working very hard to stop the rise of these deadly superbugs. In our SaS-AMR Champions Series, commemorating the World Antimicrobial Awareness Week (WAAW2021), we bring to you conversations with some of these ‘Superheroes Against Superbugs’ that we hope would inform, inspire, and encourage us all to act against AMR to ensure a healthy future for all.

Philip Mathew is a public health researcher and currently AMR advisor at The International Centre for Antimicrobial Resistance Solutions. Philip also served as a consultant at the ReAct Asia Pacific, a global network dedicated to tackling the problem of antibiotic resistance. ReAct was one of the first international networks to articulate the complex nature of antibiotic resistance and advocates for the need for multidisciplinary and multisectoral collaborations in addressing it. Philip recently spearheaded a consultation meeting with a diverse set of stakeholders including, Superheroes Against Superbugs, on the feasibility of a State Action Plan on AMR in Telangana.  In this interview, Philip takes us through various ways in which ReAct is spreading awareness and promoting community and policy action to address the growing problem of AMR in India and globally. 

You have been a part of ReAct since 2017, what got you interested in this organization?

ReAct is an international science-based network, working on the issue of antibiotic resistance since 2006. For me, ReAct was an organization that could integrate policy action, community interventions and advocacy around the AMR issue and help the various stakeholders get a holistic perspective. It brought together public health professionals, policy experts, microbiologists, infectious disease physicians, pharmacologists, communicators and basic scientists, across its five offices in various continents. This diversity in staff and a very open working environment that promotes innovative thinking, has always been the USP of ReAct. 

For me, ReAct was an organization that could integrate policy action, community interventions and advocacy around the AMR issue and help the various stakeholders get a holistic perspective.

What are some ways in which ReAct is trying to address the problem of AMR? 

Various continental nodes of ReAct have been focusing on different approaches towards tackling the AMR issue. For example, ReAct Europe has always worked on translating evidence for consumption by the policy community while ReAct Latin America has worked to find levers for engaging communities and social movements on AMR. ReAct Asia Pacific is a young node and was initiated only in 2016. We have been working to broad base the uptake of AMR interventions among various community stakeholder groups. We are trying to achieve this through piloting scalable community-based interventions among small-holder farmers, local self-government institutions and students. These are all implementation research projects and we look to harvest the learnings from the process. ReAct Asia Pacific is also trying to assess the community-level impact of the first edition of National Action Plans, in select countries of south and south-east Asia. Besides, this is being done with an aim of advocating for a bottom-up strategy to complement the current top-down narrative in most National Action Plans. We have also been trying to stimulate the framing and implementation of state action plans on AMR in India, given the unique federal structure in the country. In short, ReAct Asia Pacific is trying to address the issue of AMR using a systems approach, fully understanding that the broken healthcare delivery and agricultural systems contribute heavily to the issue. 

Can you tell us more about the ASPIC clubs in India and the Antibiotic Resistance Coalition initiative of ReAct? 

ASPIC actually stands for Antibiotic Stewardship and Prevention of Infection in Communities. This is a network of student clubs that we have seeded in universities and colleges in two states of southern India. The clubs recruit students who are interested in advocacy about healthcare issues and motivate them to work on the AMR issue. Each club is a self-governed entity and ReAct Asia Pacific supports them through seed grants, competitions, seminars and an annual meeting. Our aim is to find out the feasibility of this strategy and understand the nature of specific deliverables which can be expected from students’ engagement on AMR. Since its launch in 2018, we now have 16 clubs in the network. We are also in the process of launching an ‘ASPIC Junior’ network for schools. 

Antibiotic Resistance Coalition (ARC) is a high-level network of civil society organizations, who want to address the AMR issue through international collective action, global policy interventions and increased accountability at all levels. They want to bring transparency in antibiotic research & development, increase funds for innovations to tackle AMR and amplify the voice of low-middle Income countries. All the organizations which are a part of ARC have to endorse a declaration about the basic principles of the organization. ARC now has members from all continents and the secretariat of the network is ReAct North America, based at the Bloomberg School of Public Health, Johns Hopkins University. They regularly make policy interventions and provide feedback to intergovernmental agencies about any proposed actions with an interface with AMR. 

Even though AMR is a critical public health challenge for India, why do you think we have not managed to mobilize sufficient social and political action to address this problem?

AMR is still seen as an abstract medical issue, which may affect us sometime in the future. We have to break down these false perceptions if we want to mobilize more social and political capital. The non-healthcare dimensions of AMR are still hidden, just like the fact that AMR is already killing hundreds of thousands of people. There is a big gap between the scientific community and policymakers, due to inappropriate messaging strategies and differences in ‘language’. This is affecting the flow of resources and the sustainability of interventions. We also do not have a proper investment case for AMR at the country level. The policy community needs to be sensitised about the real impact of AMR on the economy and the healthcare system. Lastly, we need to broaden this issue and create more ownership for AMR interventions in local communities. For that, we need to understand the messaging frames for each stakeholder group and the levers to co-opt them into the action on AMR. 

AMR is still seen as an abstract medical issue, which may affect us sometime in the future. We have to break down these false perceptions if we want to mobilize more social and political capital.

What are some major challenges that you have faced in your AMR advocacy work? and if at all, how did you overcome them?

Inter-sectoral involvement and behavioural change have been the biggest challenges so far. It has been relatively easy to engage healthcare groups on the AMR issue, but breaking it down for agriculture and environment professionals have been really hard. Besides, finding the right tools to incentivise behaviour change has also been challenging. The AMR issue is so complex that defining positive behaviour from each stakeholder group is very difficult. One Health has become a buzzword in the last few years, but making the sectors talk to each other to design joint interventions or design incentive structures, has been a problem. Coordination between various sectors is still not optimal and this is the biggest barrier in operationalizing One Health. 

One Health has become a buzzword in the last few years, but making the sectors talk to each other to design joint interventions or design incentive structures, has been a problem.

Can you tell us about any initiatives tackling AMR that you have found to be unique and impactful?

It may be a bit of advertisement, but the ‘Antibiotic Smart Communities’ project of ReAct Asia Pacific has been quite unique, though it’s quite early to measure impact. The project aims to define an ‘Antibiotic Smart’ community, design a scorecard for ‘antibiotic smartness’ and frame an action agenda to increase the scores if needed. It looks at various AMR specific and AMR sensitive interventions which are possible in community-settings; and provides multiple tools to engage stakeholder groups. The project is now being implemented in a 15,000 strong rural community in the state of Kerala. The project can empower local communities to understand the AMR issue and tackle the community drivers of the problem using their own resources. Our broad theory of change is that AMR interventions will fail to bring about any sustainable difference or behavioural change unless there is pressure from the community.  

Our broad theory of change is that AMR interventions will fail to bring about any sustainable difference or behavioural change unless there is pressure from the community. 

What would be your call to action to the policymaker to help tackle AMR?

In the short-term, find more resources for implementing National Action Plans on AMR; and create more accountability for the implementation process by involving civil society and community groups. In the long term, invest in strengthening the public healthcare system, quality of agricultural production and put in place robust environmental management systems. 

Interview by Team SaS and Moneca Kaul; Moneca is a PhD researcher based at CCMB, Hyderabad. She is studying the bacterial cell wall and proteins that break this wall to accommodate new cell wall material as the bacterial cells grow and divides.

Cover Art by Rupsy Khurana