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Antimicrobial resistance (AMR) is a natural process where microbes develop the ability to survive the antimicrobial drugs we depend upon to treat and prevent deadly infections, such as antibiotics. This microscopic evolution is further propelled by human activities, where each use of an antimicrobial drug potentially induces AMR. As microbes can spread quickly from animals to humans and travel around the world through humanity's global circuits of movement, the use of any antimicrobial drug has potentially global consequences. As human-induced AMR occurs, mortality and morbidity increase due to increasingly or sometimes completely ineffective antimicrobial treatments. This article considers AMR as a product of the evolving and complex interplay between human societies and invisible microbial worlds. It argues that as a political challenge, AMR requires robust institutions that can manage human–microbial interactions to minimize the emergence of drug resistance and maximize the likelihood of achieving effective antimicrobial use for all. Yet, current governance systems for AMR are ill-equipped to meet these goals. We propose a conceptual paradigm shift for global AMR governance efforts, arguing that global governance could better address AMR if approached as a socioecological problem in need of sustainable management rather than solely as a medical problem to be solved. In biodiversity governance, institutions are designed to fit the biological features of the ecosystems that they are attempting to manage. We consider how a similar approach can improve global AMR governance. Employing the concept of ecological fit, which is defined as the alignment between human social systems and biological ecosystems, we diagnose 18 discrepancies between the social institutions that currently govern AMR and the ecological nature of this problem. Drawing from lessons learned in biodiversity governance, the article proposes five institutional design principles for improving the fit and effectiveness of global AMR governance. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) causes over 1.27 million deaths annually, making it one of today's most urgent health threats. Given its urgency, there are often calls for large‐scale global initiatives to address AMR. However, theories of collective action have yet to be applied to the problem in a systematic and holistic manner. Fuller engagement with collective action theory is necessary to avoid three risks, namely: mischaracterizing the kinds of challenges that AMR presents; over‐simplifying the problem by reducing it to a single type of collective action problem while ignoring others; and overstating the ability of collective action theory to formulate effective solutions. This article relies on the work of Elinor Ostrom to develop an analytical framework for collective action problems around public and common goods. When analyzed through this framework, we find that AMR poses at least nine distinct collective action problems. This more granular framing of AMR provides, in our view, a better basis to develop policy solutions to address this multifaceted challenge. We conclude with proposals for future research. [ABSTRACT FROM AUTHOR]

Background Population-level factors within and beyond the scope of the World Health Organization's (WHO) MPOWER policy package have significant impacts on smoking rates. However, no synthesis of the existing evidence exists. This systematic review identifies population-level factors that influence cigarette smoking rates in European countries. Methods We searched the ProQuest database collection for original, peer-reviewed quantitative evaluations that investigated the effects of population-level exposures on smoking rates in European countries. Of the 3122 studies screened, 62 were ultimately included in the review. A standardized data extraction form was used to identify key characteristics of each study including publication year, years evaluated, countries studied, population characteristics, study design, data sources, analytic methods, exposure studied, relevant covariates and effects on tobacco smoking outcomes. Results One hundred and fifty-five population-level exposures were extracted from the 62 studies included in the review, 99 of which were related to WHO MPOWER measures. An additional 56 exposures fell into eight policy realms: economic crises, education policy, macro-economic factors, non-MPOWER tobacco regulations, population welfare, public policy, sales to minors and unemployment rates. About one-half of the MPOWER exposures affected smoking rates (55/99) and did so in an overwhelmingly positive way (55/55). Over three-quarters of the non-MPOWER exposures were associated with statistically significant changes in smoking outcomes (43/56), with about two-thirds of these exposures leading to a decrease in smoking (29/43). Conclusions Population-level factors that fall outside of the WHO's MPOWER measures are an understudied research area. The impacts of these factors on tobacco control should be considered by policymakers. [ABSTRACT FROM AUTHOR]

Global antimicrobial resistance (AMR) is currently governed by a decentralized regime complex composed of multiple institutions with overlapping and sometimes conflicting principles, norms, rules, and procedures. Such a decentralized regime complex provides certain advantages and disadvantages when compared to a centralized regime. A pandemic instrument can optimize the regime complex for AMR by leveraging the strengths of both centralization and decentralization. Existing climate treaties under the UNFCCC offer lessons for achieving this hybrid approach. [ABSTRACT FROM AUTHOR]

To address the complex challenge of global antimicrobial resistance (AMR), a pandemic treaty should include mechanisms that 1) equitably address the access gap for antimicrobials, diagnostic technologies, and alternative therapies; 2) equitably conserve antimicrobials to sustain effectiveness and access across time and space; 3) equitably finance the investment, discovery, development, and distribution of new technologies; and 4) equitably finance and establish greater upstream and midstream infection prevention measures globally. Biodiversity, climate, and nuclear governance offer lessons for addressing these challenges. [ABSTRACT FROM AUTHOR]

Ensuring that life-saving antimicrobials remain available as effective treatment options in the face of rapidly rising levels of antimicrobial resistance will require a massive and coordinated global effort. Setting a collective direction for progress is the first step towards aligning global efforts on AMR. This process would be greatly accelerated by adopting a unifying global target — a well-defined global target that unites all countries and sectors. The proposed pandemic instrument — with its focus on prevention, preparedness and response — represents an ideal opportunity to develop and adopt a unifying global target that catalyzes global action on AMR. We propose three key characteristics of a unifying global target for AMR that — if embedded within the pandemic preparedness instrument — could rally public support, funding, and political commitment commensurate with the scale of the AMR challenge. [ABSTRACT FROM AUTHOR]

This article critically examines the use of national border closures at the outset of the COVID-19 pandemic. After explaining why targeted border closures generally do not work and how they violated international law at the time, we examine the unprecedented case of total border closures. Positing that since the current instruments and institutions of global health governance did not anticipate this phenomenon, the legality of total border closures rests on less certain grounds. Then, after asking why nearly every government implemented some form of border closure in March 2020 if neither science nor law provided adequate motivation for their use, we conclude that in the face of a global health emergency, border closures represent an opportunity for political leaders to show determined action, redirect blame to other jurisdictions, and reinforce nationalism. We proceed to argue that both targeted and total border closures have profound legal, epidemiological, and political significance as performances that contradict global realities while undermining notions of global solidarity. Such political theatre means that citizens must weigh these consequences against any perceived benefits of border closures as they would any other politically driven government action, and contest and challenge them appropriately. Citizens must not unduly defer to scientists or lawyers on early COVID-19 border closures because these were primarily political—not scientific or legal—decisions. In this vein, we conclude with some guiding political considerations for scrutinizing government decisions to close borders and observations for the future of global health cooperation during infectious disease outbreaks. [ABSTRACT FROM AUTHOR]

An editorial is presented in which the authors discuss several aspects of the Paris Agreement under the United Nations Framework Convention on Climate Change that may be significant and applicable in global governance of antimicrobial resistance (AMR), particularly in the wake of the COVID-19 pandemic. The authors call for an international treaty concerning pandemics.

Nutrition guideline development is traditionally seen as a mechanism by which evidence is used to inform policy decisions. However, applying evidence in policy is a decidedly complex and politically embedded process, with no single universally agreed-upon body of evidence on which to base decisions, and multiple social concerns to address. Rather than simply calling for "evidence-based policy," an alternative is to look at the governing features of the evidence use system and reflect on what constitutes improved evidence use from a range of explicitly identified normative concerns. This study evaluated the use of evidence within the Canada Food Guide policy process by applying concepts of the "good governance of evidence" – an approach that incorporates multiple normative principles of scientific and democratic best practice to consider the structure and functioning of evidence advisory systems. The findings indicated that institutionalizing a process for evidence use grounded in democratic and scientific principles can improve evidence use in nutrition policy making. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) is one of the defining global health threats of our time, but no international legal instrument currently offers the framework and mechanisms needed to address it. Fortunately, the actions needed to address AMR have considerable overlap with the actions needed to confront other pandemic threats. [ABSTRACT FROM AUTHOR]

In 2015, 196 countries boldly committed to address global antimicrobial resistance (AMR). Now, five years later, progress reports suggest the implementation of AMR activities is vastly below what was initially promised. The challenge of overcoming the 'commitment-compliance gap' is not unique to AMR and is common in other areas of international politics. Global health policymakers can therefore learn from theories of international relations and experience in other sectors. We reviewed international relations scholarship to generate five hypotheses for why states might comply or not comply with their global commitments. We then conducted a public policy analysis of three past international agreements on biological diversity, climate change, and nuclear weapons to test these hypotheses and identify lessons for encouraging country compliance with global health agreements, with specific application to global AMR policies. To bridge the commitment-compliance gap, international leaders should: (1) frame incentives to maximise interests for action; (2) pursue enforcement mechanisms to induce state behaviour; (3) emphasise building a culture of trust by providing mutual assurance for action; (4) include mechanisms for managing poor performers; and (5) find opportunities for continual social learning. Agreements should be designed with flexibility, data sharing, and dispute settlement mechanisms and provide financial and technical assistance to states with less capacity to deliver. [ABSTRACT FROM AUTHOR]