Here's what people expect to happen when they are prescribed an antibiotic:
- They take the drug.
- They get better.
But this smooth path from sick to healed, bridged by the powers of antimicrobials, is quickly becoming a rocky one. Thanks to antimicrobial resistance (AMR), health care practitioners may try a handful of drugs before they find one that works for a patient-if they can find one. The patient may ultimately die from an infection that, not long ago, was entirely preventable.
It's a dire picture that is becoming increasingly common. Over the next 25 years, an estimated 39 million people are expected to die from drug-resistant pathogens alone. That's over 5 times the number of deaths from COVID-19 in the last 4 years.
And yet, for all the devastation, AMR is largely absent from public consciousness. It's a fraction of a blip on the day-to-day radar. In fact, AMR is routinely called "the silent pandemic" because of the way it lurks, relatively unnoticed and underdiscussed, while wreaking havoc and claiming lives.
"The numbers are there," said Anirban Mahapatra, Ph.D., Editorial Director of ASM Journals and author of When The Drugs Don't Work: The Hidden Pandemic that Could End Modern Medicine. "[AMR will cause] an economic catastrophe. It will kill more people than COVID at its height. But why are people not talking about it?"
In other words, how can something so big be so quiet? And how can we turn up the volume?
A Slow-Burning Fire
To understand AMR's silence, it helps to compare it with something loud. On the global soundstage, disease snags widespread attention when it emerges with a boom and a crash. Think about the COVID-19 pandemic: a new pathogen (SARS-CoV-2) started spreading in the human population, causing a handful of infections that quickly rose into the hundreds of thousands, leading to tens of thousands of deaths.
Extensive media coverage of COVID-19-the novelty of it, coupled with its avalanching devastation and requirement for immediate, widespread behavioral modifications to staunch the spread (masking, social isolation and distancing)-launched it into public conversation, where it has lingered (facilitated by the continued spread of the virus).
AMR is different, a slow-burning fire to COVID-19's inferno. Physiologically, AMR is as old as microbes themselves; its evolution has diverse functions in natural populations. That means that "even if we didn't [use antibiotics], resistance would still be there," Mahapatra said. "So, you want to tell people to not misuse antibiotics, but that's to prolong the life of the antibiotics, and not that resistance is never going to happen. It's already out there. That's a difficult concept to get across to people."
Indeed, AMR was a clinical issue soon after the discovery and use of penicillin. But though the problem has gotten more pressing, there is no acute, world-changing shift that everybody experienced-no collective "before" and "after." AMR just naturally exists. And in a media landscape fueled by novelty, where the shift is the story, the problem fails to surface.
Big, Complicated and Ambiguous
That AMR is a complicated concept to communicate also has something to do with its low-key status.
"Those of us in the AMR space, we haven't figured out how to share the risk with the general public, and therefore they aren't activated and doing things about it," said Diane Flayhart, MBA, Director of Global Public Health, AMR at Becton, Dickinson and Co. (BD). She highlighted that COVID-19, tuberculosis and HIV have successfully garnered attention and funding because they are tied to a single organism that can be easily described and understood. The arithmetic is relatively straightforward: pathogen + infection by that pathogen = not good.
AMR is more like algebra-there are multiple variables and layers to the problem. For one, AMR is not an infection, but a phenomenon. It's not caused by a single infectious agent but is associated with countless infections caused by diverse organisms. And those organisms aren't always bad. Someone may have a drug-resistant strain of E. coli living harmlessly in their gut, and it's only problematic if it gets into, say, the urinary tract and can't be cleared via antibiotics. Slip the AMR issue behind a One Health lens, which adds environmental and animal variables to an already highly contextual and nuanced problem, and one can almost hear the collective confusion.
In some ways, the relative whisper of AMR may be because it's so big, pervasive and diverse in its manifestation, it becomes a bit unwieldly. "I think that's probably why [AMR] is silent-it's in a very large kind of ambiguous space that we're trying to describe to people and then get them passionate about it, and that's hard to do," Flayhart explained.
Who Is Affected-and Where-Matters
There's also the fact AMR is a problem literally hidden from view. The battles against AMR infections are often waged in institutional settings most people don't think about unless they are in one, like hospitals and health care centers. Getting the word out means sharing the stories of those on the inside. But, as Mahapatra pointed out, people facing the brunt of AMR's impact often "don't have the loudest voices." The U.S. Centers for Disease Control and Prevention states that AMR infections largely impact young children and people at higher risk of health disparities and inequities, including "groups that have historically experienced greater obstacles based on their racial or ethnic group."
There's a geographic component to the issue too. People in low- and middle-income countries are at the forefront of the AMR crisis, due to a variety of infrastructural and systemic factors that increase the burden of disease and antibiotic use. However, the disproportionate impacts of AMR on these groups are often absent from the broader conversation. This is not uncommon; diseases/infections impacting low- and middle-income regions do not routinely crop up in the news cycle in countries like the U.S. unless they may pose a threat to those countries themselves (recent mpox outbreaks offer a poignant example).
Of course, AMR is already a threat to every country on the planet-but where hot spots are located can influence who hears about it, and when.
The Importance of (Large) Advocacy Groups
Regardless, there is power in numbers; when people band together, they can do a lot for surfacing and magnifying the burdens of disease. And yet, "there isn't a large population that is affected by [AMR] at one time," said Ella Balasa, a patient advocacy and engagement consultant living with cystic fibrosis who has routinely battled AMR infections in her lungs. She noted that many people may get an infection and, if it is resolved, go back to their normal lives. "They have this blip of dealing with an antibiotic-resistant infection, and it was perhaps a very traumatic experience. But then, if they recover, they don't always go on to be strong advocates in this space," she shared. Flayhart agreed; based on her experience interviewing patients who survived AMR infections, many are hesitant to talk-they want to move on and forget.
For conditions like HIV or tuberculosis, there is a much broader pool of passionate advocates because of the longevity of the fight the diseases require. "With AMR, it's predominantly bacterial infections. Those either resolve quickly because you get the right treatments, or they don't resolve, and, unfortunately, the patient does not survive," Flayhart stated.
The AMR issue does have its share of passionate advocates; Balasa is a stark example of that. Among other roles, she acts as an advisor to the AMR Narrative and a member of the World Health Organization Task Force for AMR Survivors, the latter of which consists of patient and caregiver survivors that have experienced AMR infections. "We're aiming to bring to light and humanize the experience of AMR on a broader global scale [by] partnering with local government organizations across the globe," she said.
Yet, this is only the tip of what needs to be a sizable iceberg. According to Balasa, public awareness will only grow from developing large campaigns that bring big organizations and companies together to share messages about AMR, including news sources and sites. Right now, "there isn't a lot of unity, like a large presence or large voice. There're a lot of siloed efforts."
How Can We Make the AMR Pandemic Louder?
Which raises a key point: understanding why the public doesn't talk about the AMR pandemic is 1 thing, but getting people to talk about it is another. Facilitating conversation, passion and action around AMR is, like the issue itself, multi-faceted.
Rope in the Government
"It's not just activating people and their behavior," Flayhart said. "There's also the element of, 'How do we get our governments to pay for and fund what needs to happen?'" She noted that if governments were putting money toward AMR, people would likely pay more attention. While many countries have national action plans outlining how to deal with drug resistance, a limited number have money behind them. There are successful initiatives-the Fleming Fund, a government-managed aid program based in the U.K. that supports action against AMR in low- and middle-income countries is an example-but more action is needed.
In the U.S., progress has been relatively slow. A couple of bills aimed at promoting development of new antibiotics and appropriate use of existing drugs, and strengthening responses to AMR outbreaks, have been (re)introduced by Congress over the years. But, so far, they have not been passed.
The good news is that scientists and other stakeholders are working to facilitate governmental action, in the U.S. and beyond. ASM is a leader in initiating conversations between scientists and policymakers to help manage the AMR crisis. A recent example: ASM members met with policymakers in September 2024 to discuss global lab capacity and access to diagnostics as a key component of combating AMR, and the role of the U.S. in increasing that capacity and access. That same month, the United Nations General Assembly hosted a high-level meeting on AMR, which ASM leaders attended, that brought together political leaders from around the world to discuss approaches for addressing AMR on a local, national and global scale. While these efforts don't automatically thrust AMR into public consciousness, "it's a great start," Balasa said.
Get Out of the AMR Bubble
Another important step is to "broaden the conversation with other advocacy and stakeholder groups that are being impacted by the infections," Flayhart said. This means that those working in the AMR space must figure out who is being most affected and make connections with them.
For example, cancer patients have a nearly 2-fold higher risk of developing an AMR infection than those without cancer. Raising awareness about AMR in the cancer community could bring the problem out of the shadows by tacking it onto an issue that already has a spotlight. According to Flayhart-who is helping to lead the Antimicrobial Resistance Fighter Coalition's Cancer and AMR Consortium- "if we can get the cancer advocacy groups, which have large funding and huge power, to say that antibiotics are a critical tool for cancer care, then I think that kind of shifts. So how we make it non-silent is finding people who really care and have the power and the bandwidth to then make sure that their voices are heard."
Tell Stories
How those voices are shared matters, too. The discourse around AMR is riddled with data, acronyms and pathogen names. Firing off the number of cases, deaths and impacts from AMR is often a go-to method to say "See? This is a huge problem!" But Mahapatra emphasized that numbers don't resonate with people. What does resonate is compelling stories about other human beings. It is through creatively featuring the experiences of individuals, of giving a human face to the devastation, that makes people more inclined to care. And when they care, they are more likely to act-which may involve further amplifying the issue.
It's also worth framing AMR as a personal problem, even (especially) if people don't see it that way. Mahapatra shared that in India, where he is from, "there is unfettered access to antibiotics. People take them without going to a physician." This can exacerbate the spread of AMR through inappropriate antibiotic use. Communicating that such use of antibiotics has negative implications for someone's health (e.g., destroying their microbiome, increasing susceptibility to other infections) could help people see that "they have a personal stake here, even if we think of the antibiotic issue as a tragedy of the commons." Using terminology like "untreatable infections" versus acronyms like "AMR," which may be confusing, can add further clarity.
Within that vein, demonstrating that AMR infections can happen to anyone is critical, Balasa said. "Highlighting the stories of people who have been completely healthy for the entirety of their lives, and maybe they have a surgical procedure done, and they get an acquired hospital infection that's very devastating…Those are the stories that I think really hit home for people."
Time to Get the Show on the Road
At a time when the world's attention has been captured by novel pathogens, when a key question is "What will emerge next?" it pays to look at the big problems that are already here. The AMR pandemic is quiet, but it's snowballing. We can amplify it now to soften the noise later, or we can wait until it becomes cacophonous on its own, when our methods for dampening the sound are less effective. The time to act is now.
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