The invisible pandemic of antimicrobial resistance and its possible endings

ABSTRACT

Antimicrobial resistance (AMR) is often framed as a ‘silent pandemic,’ an invisible crisis unfolding beyond the public gaze. This unseen emergency narrative fuels policy responses aimed at re-establishing human control over antimicrobial use and benefits. In this commentary, we critique the reduction of AMR to a homogenising framework – a product of long-standing paradigms for disease control and elimination. We argue that AMR stems not merely from microbial exposure to drugs, but also involves broader anthropocentric practices. We assert that merely extending AMR concerns to encompass environmental factors is insufficient. Instead, we advocate for a paradigm shift towards a holistic understanding that respects the evolutionary adaptability and survival strategies of microbial life itself. Consequently, a fundamental re-evaluation of large-scale antibiotic use and production is necessary. Rather than seeking to control AMR as a pandemic, we propose exploring the inherent complexity and interdependence of AMR issues. Our proposition advocates for alternative futures that foster collaborations between human and non-human actors, ultimately envisioning a shift in human-microbial relationships towards more integrative health strategies.

KEYWORDS:

• Policy
• pandemic
• future
• disease elimination
• antimicrobial resistance

Introduction

Antimicrobial resistance (AMR) is widely recognised as a significant global threat to public health and development (WHO, 2019). In response, the World Health Organization (WHO) introduced the Global Action Plan (GAP) on AMR in 2015, which outlines strategies to safeguard modern medicine and mitigate the risk of a post-antibiotic world (WHO, 2015). The GAP advocates for a collaborative approach involving the World Organisation for Animal Health (OIE) and the UN Food and Agriculture Organisation (FAO), promoting a comprehensive ‘one-health’ strategy to combat AMR (WHO, 2015). This joint effort, also now including the United Nations Environment Programme (UNEP), led to the establishment of the AMR Leaders group (AMR Leaders, 2024). To support the implementation of action plans, their main task is to secure political commitment, as emphasised at the latest UN General Assembly High-level Meeting on AMR in April 2024 (UNEP, 2023a). The urgency is palpable: ‘There is no time to wait!’ warns the WHO in its 2019 report (WHO, 2019).

A recurring theme across the global AMR policy landscape is that resistance is propelling humanity toward a post-antibiotic era – a time when minor infections and routine surgeries might once again prove fatal. Policy documents underscore this bleak prospect with projections and forecasts. Yet, they also offer a glimmer of hope: the possibility to avert this crisis exists. It hinges on human ability to swiftly mobilise substantial funds and public attention, converting these resources into strategic actions to maintain our control over infectious diseases worldwide.

In this commentary, we critically examine the prevalent messaging of the threat of uncontrolled microbes in AMR policies and agendas. We propose that global dialogues and initiatives targeting AMR are entrenched in, and consequently perpetuate, anthropocentric perspectives – those that prioritise human interests and advocate for human dominion over nature (Kamenshchikova et al., 2021). Labelling AMR as a ‘pandemic’ aligns it with important epidemics like HIV, tuberculosis, and malaria, as noted by Laxminarayan (2022). This framing situates AMR in the context of disease control and eradication, contributing to a narrative that has powerful repercussions in global health discussions (Overton et al., 2021). It rekindles memories of historical confrontations with infectious diseases while bolstering confidence in the efficacy of international health campaigns aimed at disease eradication, thereby serving to captivate specific groups and secure funding (King, 2004).

However, criticism of disease control and elimination initiatives highlights their shortcomings, ethical quandaries, and the possible unforeseen outcomes (Adams, 2016; Craddock, 2000). A disproportionate focus on individual diseases can lead to an inequitable allocation of resources (Pfeiffer & Chapman, 2010). This narrow approach can also overshadow fundamental issues within health systems, failing to address the broader determinants of health (Spiegel et al., 2015). Simplifying intricate health challenges to merely technical problems amenable to biomedical solutions or cost-effective strategies often ignores the crucial social, political, and economic dimensions that drive disease emergence and persistence (King & Koski, 2020).

We assert that many of the limitations and adverse outcomes associated with disease control and eradication efforts stem from an anthropocentric outlook on health and disease – an outlook that places human health in opposition to nature, prioritising human needs over other life forms and the environment. The exclusive focus on reducing human disease has known repercussions on the wider ecosystem and biodiversity (Wolf, 2015). Notably, disease elimination strategies often over-emphasize biomedical solutions without suitably considering broader socio-ecological contexts (Wallace et al., 2015).

In this paper, we posit that categorising AMR within the paradigm of disease control and eradication may perpetuate efforts primarily directed towards microbial containment. This approach risks repeating past errors associated with disease elimination programmes. Our apprehension is that a myopic focus obstructs understanding AMR as a complex biosocial phenomenon. Therefore, we argue for AMR to be approached as a nuanced interaction of biological and societal factors in the future. AMR should not be interpreted as our failure to control, but rather as a continual adaptation of microorganisms to the relentless exploitation and overuse of microbial products for human advantage.

Illustrating with the case of resistant tuberculosis in India, we elaborate on how anthropocentrism shapes AMR policies and responses, potentially fostering resistance rather than mitigating it. We put a spotlight on the anthropocentric bias in AMR research and policy that hampers strategies from acknowledging the intricate relationships between humans, microbes, and their environments. Importantly, this overlooks the socio-economic disparities that have contributed to resistance emergence. We maintain that a fundamental reconsideration of this anthropocentric paradigm is essential for addressing AMR effectively.

The past: The miracle of controlling infections and a natural history made invisible

In exploring the history of human-microbial interactions, it becomes clear that an anthropocentric paradigm has shaped the emergence of resistance, primarily through a sustained focus on maximising human benefits from microbial products. The capacity of microbes to resist medicines has been known since penicillin was first discovered. Alexander Fleming issued a warning during his acceptance of the Nobel Prize: ‘It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body’ (1945, p. 93). Despite this, resistance was not given due priority in laboratories, hospitals, or more generally in public health, as the excitement over the seemingly miraculous effects of new drugs – and the potential profits they promised – prevailed (Landecker, 2016). As new medicines were continually developed, with ineffective ones being replaced by more potent counterparts, resistance was viewed more as an issue of slow industrial production that had to be solved, rather than a result of microbial evolution (Landecker, 2016). While the investigation into bacterial evolution was concurrently unfolding within microbiology (Lane, 2015), it was largely overshadowed as the human endeavour to control infectious diseases through antibiotic industrialisation monopolised the attention and resources (Landecker, 2016).

The journey from the initial purification to the first clinical application of penicillin spanned over a decade, with it taking nearly two decades for the industry to optimise the use of more productive Penicillium strains (Gaynes, 2017). Propelled by military and commercial interests, mass production of antimicrobials was quickly scaled up impressively (Landecker, 2016). Concurrently, the serendipitous finding that antibiotic waste could enhance growth in livestock rapidly translated into commercially viable feed supplements, a development intrinsically grounded in anthropocentric values (Seeberg, 2020b). Despite international reports from the 1960s on the risks associated with low-dose antibiotic use in farm animals, these prompted scant global response or concrete measures (Kirchhelle, 2018; Overton et al., 2021). Today, approximately half of global antibiotic consumption is attributed to animal agriculture and aquaculture (Davies, 2006), and antibiotics are deemed infrastructural for human and animal productivity (Tompson & Chandler, 2021).

The historical focus on the productivity and ‘magical’ therapeutic benefits of antibiotics has resulted in a significant oversight of their broader ecological impact and a failure to appreciate the inherent dynamics of microbial life and historical evolution (Chandler, 2019; Gaynes, 2017). Microbial life has thrived on Earth for billions of years, evolving sophisticated mechanisms to compete for space and resources, such as the development of antimicrobial capabilities (Granato et al., 2019). The capacity to withstand and multiply in the presence of competing microbes is critical for evolutionary success within complex ecosystems (Granato et al., 2019). The phenomenon of microbial resistance is embedded in this vast evolutionary tapestry, where resistance genes are a natural component of all microbial ecologies (Spagnolo et al., 2021). Antibiotic resistance, therefore, is not just induced in bacteria by exposure to antibiotic-rich environments through mutation and gene transfer; it also arises from the expression of pre-existing resistance genes in both pathogenic and non-pathogenic bacteria, a testament to their evolutionary heritage (Smalla et al., 2015).

Evidence suggests that the natural occurrence of antibiotics is minimal in pristine soils, indicating that resistance genes have evolved well before the human use of antibiotics (Davies, 2006; Martinez, 2009). In addition, the inherent mobility of these resistance genes allows bacteria to disperse and adapt to new environments, altering the selection dynamics and favouring the survival of adapted variants (Baym et al., 2016). As humans continue to saturate environments with bioactive molecules, the impact of this excess on microbial evolution and ecosystems of multiple scales remains an unfolding narrative (Landecker, 2016).

The future: Global policies and the quest to eliminate a threat to humans

The current AMR landscape reflects an ongoing pursuit of immediate human benefits, often at the expense of acknowledging the natural history of microbial evolution. This scenario results from a paradigm where socioeconomic imperatives in human society either eclipse or profit from fundamental microbial processes. In an imaginary remediation of the AMR crisis, one might envision a future where environmental pollution from bioactive substances is curtailed and a harmonious coexistence between humans and microbes is reinstated. However, in reality, the dominant global health frameworks for addressing AMR – largely influenced by disease control paradigms – rarely encompass such ecological balance. Instead, they continue to perpetuate an anthropocentric viewpoint, portraying microbes primarily as adversaries to be controlled for human welfare (Nerlich & James, 2009).

WHO’s Global Action Plan (GAP) is an example of such a policy, developed from a renewed interest in AMR within global health, sparked by the threat of re-emerging infectious diseases, pandemics, and biosecurity concerns. This policy framework was heavily shaped by projections of AMR's potential to exacerbate human suffering and economic burdens (Overton et al., 2021). The overall global health focus on daunting statistics, such as the potential for AMR to cause 10 million deaths annually and cost up to 100 trillion USD by 2050, has framed resistance as a dire threat on par with other critical global health challenges, including HIV, malaria, and, more recently, COVID-19 and tuberculosis (Laxminarayan, 2022; Murray et al., 2022; O’Neill, 2016).

Amidst the urgency communicated by predictions of potential AMR-induced economic and human catastrophe, the global health strategy adopts a ‘sentinel approach’ that prioritises AMR as an imminent concern and ensures its prominence on the global health agenda while overshadowing competing interests (Chandler, 2019; Overton et al., 2021). The reliance on statistical estimates not only secures public and private funding for AMR initiatives but also perpetuates historical narratives of disease outbreaks in tropical, low – and middle-income countries (Cars et al., 2021; Chaudhry & Tomar, 2017; Mendelson et al., 2022). Thus, the constructed image of a dire infectious future lurking in the global south informs and influences current actions and responses in the global health landscape.

Established infection control measures such as standardised surveillance and monitoring, enhanced hygiene and sanitation, public awareness campaigns, vaccination programmes, and health systems approaches are central to the worldwide effort to tackle AMR (WHO, 2015). Within the five strategic priorities of the WHO's GAP, improving surveillance and enhancing capacity are pivotal (WHO, 2015). A key development in this domain has been the formation of the Global Antimicrobial Resistance and Use Surveillance System (GLASS), which seeks to standardise data collection across countries to better inform policy-making, infection prevention, and control strategies (WHO, 2024). Borrowing the metaphor, GLASS offers a magnifying lens, intended to translate surveillance initiatives into a detailed picture of global resistance patterns, furnishing a robust foundation for targeted AMR control measures (WHO, 2024).

The appealing standardisation embedded in disease elimination strategies, though necessary, stands in stark conflict with the inherently complex nature of AMR as a global issue. Unlike the concept of a pandemic, which typically describes the widespread diffusion of a single epidemic, AMR encompasses a multitude of diverse microbes and infection scenarios, each affected by distinct socioeconomic, cultural, and political factors (Butcher et al., 2021; Schnall et al., 2019). While GLASS is ambitiously intended to monitor varying pathogens, delineating the prevalence of AMR and potential intervention points, its reliance on data standardisation is significantly complicated by local specificities (Chandler, 2019). These specificities produce unique variations of the problem, challenging both, the data collection process and the application of standardised control measures (Adams, 2016).

Studies on the implementation of global AMR surveillance in low and middle-income countries reveal that local social and material conditions interfere with the processes of data standardisation and transfer (Thakral et al., 2022). When infrastructure tools needed for AMR surveillance, such as laboratory equipment, diagnostic testing, logistics, and personnel training are fragmented, diverse and inconsistent data outcomes are observed at national levels (Sariola et al., 2022). Furthermore, in settings where baseline capacities are lacking, targeted measures often are short-lived and overlook broader systemic issues, indicating that unsuccessful implementation of AMR policies is reflective of deeper structural problems rather than improper adherence (Sariola et al., 2022; Tompson & Chandler, 2021).

By default, AMR surveillance methodologies tend to neglect the broader socio-economic contexts within which microbes and humans coexist in an interdependent environment. Factors such as limited access to diagnostics and quality medicines, cultural beliefs regarding drug use, industrial pollution, as well as poverty and social inequalities that lead to poor hygiene and sanitation, are critical drivers of AMR. Data captured through systems like GLASS fail to take these elements into account, often leading to oversimplified and paradoxical interventions (Chandler, 2019). For instance, a prime focus of AMR policy is on antimicrobial stewardship and prescription control, especially since the global trend of antibiotic overuse is identified as a leading cause of resistance (Hall et al., 2022). However, this strategy does not account for the stark realities in many low-income areas where the issue is not excess, but a lack of basic antimicrobial treatments (Laxminarayan, 2022). Stewardship approaches clearly highlight the inappropriateness of a one-size-fits-all solution to AMR, by overseeing how the burden of AMR is not carried equally worldwide (Laxminarayan, 2022; Laxminarayan et al., 2013).

In summary, both the definitional and technical challenges that pervade current AMR strategies are reflections of the very complexities that give rise to antimicrobial resistance. The limited availability of relevant data is not merely a problem in and of itself, but a symptom of the systemic issues that contribute to the development and spread of resistance (Chandler, 2019). Simply amassing more standardised data is unlikely to result in interventions that can effectively grapple with these intricacies. Further compounding this issue, the dominant global health discourses lean on notions of disease elimination and control, casting microbes as ‘superbugs’ to be vanquished by humans who are portrayed as besieged (Nerlich & James, 2009). This adversarial perspective leaves little room for contemplating more symbiotic human-microbial relationships or conceiving microbes in any other way than antagonistic entities. Indeed, the very framework of disease elimination risks foreclosing the opportunity to understand ‘resistance’ in the sociopolitical sense of the word – resistance as a survival technique in response to attempts at dominance and control, as we exemplify with the case description bellow.

Present complexities: Resistant tuberculosis from a biosocial perspective

Let us clarify: our argument is not to downplay the gravity of antimicrobial resistance (AMR) as suggested by current forecasts. Rather, we place AMR within other echoes of human exploitation of nature – such as climate change – to highlight that strategies fixated on human advantage and unremitting economic growth might not elicit the essential transformations needed. Existing AMR strategies may, in fact, be perpetuating historical missteps – where the human emphasis on exploiting microbes for economic gain and health benefits eclipses a deeper understanding and appreciation of microbial life and evolution. This anthropocentric perspective of the future risks discounting the real instigators of resistance, potentially dwelling into futile struggles against a perpetually adaptable natural world. Moreover, disease control-driven tactics may not possess the necessary flexibility to tailor standard measures to match the specificities of context driven resistance, leading to potentially less effective outcomes. Our concern is that AMR refractory action plans and efforts, contrary to their intent, could further amplify resistance.

The ambitious campaign against tuberculosis (TB) serves as a telling case study, demonstrating how traditional infection elimination strategies, when reconfigured as programmes for resistance control, may inadvertently cultivate conditions favourable for the emergence of resistance. Under the Stop TB initiative, the DOTS (directly observed treatment, short-course) strategy, and its expanded version DOTS+, were designed to both eliminate TB and control drug resistance (Seeberg, 2014). While global funding mechanisms facilitated the medicine-intensive DOTS programme, enabling the treatment of numerous TB patients (Seeberg, 2020a), the anticipated decline in TB incidence did not unfold in proportion with the scale-up of treatment efforts. Instead, there was a marked rise in cases of drug-resistant TB (Seeberg, 2020a). Mirroring the global health narrative that frames AMR as a predicament of unregulated use in need of enhanced surveillance, TB in India was perceived as a crisis arising from inadequate control and oversight (Seeberg, 2020a). DOTS, which almost resembled a military operation, mandated a complex regimen of multiple drugs to be taken under strict supervision – yet this aggressive strategy may have inadvertently laid the groundwork for increased resistance (Seeberg, 2020a).

We put forth the proposal of approaching the issue from a ‘biosocial’ lens, as advocated by anthropologist Jens Seeberg, to gain a different perspective on DOTS – one that would take into account the microbial viewpoint. From the perspective of a human, TB in India manifests as an epidemic caused by Mycobacterium tuberculosis, where survival hinges on the compliance to a multidrug regimen. However, from a microbial viewpoint, the initiation of DOTS could be perceived as an ‘epidemic’ of toxic compounds, in the form of pharmacological substances explicitly engineered to annihilate the bacteria (Seeberg, 2020a). In this scenario, the confluence of demands for medication uptake and the socio-economic elements of the programme provided an environment conducive for microbial refuge, survival, and a counter-response to the control programmes.

Various undercurrents shaped the context in which DOTS operated. Hierarchies forged by gender and professional status influenced the drug supply chain, creating hosts who became environments of lower toxicity for microbes due to reduced serum concentrations of antibiotics (Seeberg, 2020a). The inflexible treatment regimen, which disrupted patients’ daily lives already affected by harsh socio-economic realities, inadvertently offered yet another refuge for the microbes (Seeberg, 2020a). Moreover, health system politics inadvertently fostered spaces for bacterial resistance. As a government-backed initiative, DOTS stood in competition with pre-existing treatment schemes offered by private services and local pharmaceutical companies, which were characterised by highly variable and often insufficient medication dosages and combinations (Uplekar et al., 1998; Uplekar & Shepard, 1991). The extent of commercialisation of a serious public health problem further eroded trust in the government’s attempts to rapidly expand the programme, further strengthening market opportunities and a plethora of competing interventions and resulting in, in many cases, a heaven of relief for the microbes (Seeberg, 2014). The targets of DOTS – 70 percent detection and 85 percent treatment completion rates – were formulated by ignoring the possible interactions between various actors and the biosocial responses of the microbes in order to be quickly implemented.

In an intricate interplay, these varied aspects created biosocial spaces – sanctuaries offering relief to bacteria beyond the stressors of their immediate environments, thus promoting reservoirs of cells primed for enhanced microbial survival (Seeberg, 2020a). These contextual dynamics appear to have been the underlying forces driving TB drug-resistance in India and elsewhere (Seeberg, 2020a). However, these dynamics were obscured by the DOTS elimination and control approach, which functioned under the overconfident assumption that controlling human behaviour while disregarding patients’ living conditions would directly result in bacterial elimination. By viewing AMR as an interplay where replication of an anthropocentric control logic enhances a feedback process, it becomes clearer how DOTS may have inadvertently fostered an environment ripe for a drug resistance epidemic to flourish (Seeberg et al., 2022). Despite the clear advantages of potentially more efficient treatment plans, the prevailing emphasis on pharmacological and technological solutions that solely address disease often sidelines the importance of investing in understanding contextual and structural configurations (Seeberg et al., 2022). Crucial factors such as underfunding of public health systems, ineffectual treatment programmes offered by the commercial sector, the economic motivations of pharmaceutical industries, and the danger of targeted therapies that preserve microbial environments, frequently fall outside the scope of health programme financing policies and research (Seeberg et al., 2022; Udwadia, 2001).

Conclusion: Towards alternative futures and multiple worlds

As demonstrated, reliance on technical, emergency, and short-term interventions often narrows the scope of response by disregarding the vital restructuring of entrenched social inequities (Lakoff & Collier, 2008). Solely concentrating on surveillance and control disregards the essential need to incorporate diverse ways of understanding, experiencing, and perceiving the world and its multifaceted challenges (King & Koski, 2020). Consequently, human and technology centred policies risk fostering environments conducive to the development of resistance by neglecting to confront the true, foundational drivers of AMR, instead prioritising a narrative centred around biosecurity threats (Chandler, 2019). Although experts understand the vital role that social determinants, such as poverty and deteriorating health systems, play in the emergence of diseases, they often turn towards suggesting band-aid solutions due to the immense complexity and challenge involved in implementing broader and more holistic strategies (Barnett, 2005). Funding and initiatives that favour surveillance and containment tend to endorse a homogenised method, which can eclipse the necessity to invest in and evaluate grassroots solutions to reduce antibiotic usage, solutions that show promise but remain insufficiently studied (Sariola et al., 2022). Addressing microbial resistance may indeed require an introspective turn: ‘controlling previous modes of control’ (Landecker, 2016, p. 44).

Resistance development is increasingly recognised as the product of the intricate interplay among humans, plants, and animals within ecosystems and throughout the biosphere (UNEP, 2023b). Emerging concepts such as ‘one health’ and ‘planetary health’ reflect a growing emphasis on understanding the symbiotic human-animal-environmental relationship, aligning these discussions with broader dialogues on environmental crises and climate change (Kamenshchikova et al., 2021). Yet even as these narratives gain traction, anthropocentric perspectives can undermine the potential for genuine paradigm shifts (Cañada et al., 2022). Despite a sophisticated understanding of resistance, ‘one health’ approaches often narrow their focus, considering animals and the environment merely as tools for safeguarding human health, thereby minimising the nuances of AMR (Kamenshchikova et al., 2021). In doing so, many ‘one health’ policies largely regard domestic animals as economic units and address the environment in abstract terms, without implementing actionable strategies to truly foster healthy ecosystems (Kamenshchikova et al., 2021). Consequently, when policies revert to targeting infection control with short-term fixes without accounting for broader, long-term ecological repercussions, the ethical basis of AMR policies and practices necessitates critical examination (Cañada et al., 2022).

Increasing evidence suggests that the conventional epidemiological strategy of pursuing the eradication of individual pathogens is implausible in a world grappling with the compounded challenges of climate change, escalating inequalities and armed conflicts (Kirchhelle et al., 2020; Tompson & Chandler, 2021). These global pressures underscore the necessity to confront the deep-seated structural issues that lie at the heart of pandemics and are critical for informed research and funding priorities (Kirchhelle et al., 2020; Tompson & Chandler, 2021). Given the vast disparities in healthcare access, economic conditions, and political landscapes, ‘health’ is experienced differently across the world. Acknowledging the diverse micro-environments where microbes thrive and develop resistance against human interventions allows us to conceive of multiple ‘worlds’ of AMR. It is important to recognise that when AMR policies are adapted to align with specific contextual realities, effective solutions have been known to surface (Butcher et al., 2021). Research focusing on the unique ways in which local contexts navigate microbial-human interactions has the potential to unearth innovative and sometimes radical means of re-conceptualizing the issue of AMR as inherently diverse (Wolf, 2015).

The concept of more-than-human futures is increasingly used to contest the geopolitical power structures and nationalist barriers that seek to quarantine ‘biohazardous’ others while upholding national integrity (Haraway, 2016). This reconceptualization serves as a form of political resistance, where border-crossing microbes symbolise possibility of probiotic futures that prioritise collaborative coexistence and mutual thriving of human and non-human entities (Haraway, 2016; Sariola, 2021). Amidst aspirations for a viable post-antibiotic era, which inspire activism and involvement, novel narratives are emerging within AMR research that defy the simplistic opposition between pathogenic microbes and human wellness. Civil society's engagement is fostering a shift towards a more affirmative relationship with the microbial world, focusing on advocating for the health and management of microbes rather than their control or eradication (Kirchhelle et al., 2020; Sariola, 2021).

If resistance emerges as a consequence of human efforts to exert control, then addressing AMR requires us to critically reassess traditional narratives and cultivate new ones. A ‘more-than-human’ paradigm calls for the redirection of funds and initiatives toward finding sustainable alternatives in food production, agriculture, and disease management to decrease reliance on antibiotics (Sariola, 2021). Concrete steps have been suggested to translate such a more-than-human perspective into actionable AMR interventions. Crafting policies that are well-organised, fair, and transparently monitored presents a viable alternative to current issues of data collection, implementation, and pervasive inequality (Kirchhelle et al., 2020). By developing approaches that respect the nuances of antibiotic usage in various contexts (organised), that acknowledge and address disparities in local capacity to manage AMR (equitable), and that circulate successful models and practices (tracked), there is a pivot towards a redefined focus in AMR strategies (Kirchhelle et al., 2020). Such an approach harbours the renewed promise that international efforts, which challenge the dominant narrative of control and eradication, can pave the way for sustainable, more-than-human interactions and healthier global realities.

In conclusion, this paper has challenged the anthropocentric underpinnings of AMR global policy suggesting that traditional biomedical and technocratic paradigms have to give space to innovative and inclusive strategies in order to address the complex dynamics of resistance. By embracing a biosocial perspective and concepts such as more-than-human futures, AMR approaches might recognise the interconnectivity of life forms and the imperative to integrate non-human actors in the pursuit of sustainable health sociocultural ecosystems. In promoting diverse and connected pathways, we advocate for an expanded understanding of health – one that honours the multiplicity of relationships that sustain life and well-being on a shared planet. The insights laid out in this commentary provide a stepping-stone towards a future where the integrity of global health is maintained not through elimination and control but through an inclusive, ecologically attuned, and culturally sensitive approach to disease prevention and management.

Disclosure statement

No potential conflict of interest was reported by the author(s).