Episode 265: Antimicrobial Resistance as a Geopolitical Flashpoint with Dr. Ramanan Laxminarayan

In this episode Dominic Bowen and Dr. Ramanan Laxminarayan explore antimicrobial resistance (AMR) as a geopolitical flashpoint. Find out more about how drug resistance has already crossed the red line with untreatable infections, why AMR is not a future threat but a present crisis claiming 1.3 million lives annually, and how the erosion of antibiotic effectiveness undermines cancer care, surgery, and modern medicine. The conversation examines the political and economic reasons governments have been slow to act, the fragile economics of antibiotic development, and the risks of over-reliance on a handful of pharmaceutical firms. It also addresses the spread of multi-drug resistant infections in conflict zones such as Ukraine and Gaza, the importance of prevention through vaccines and sanitation, and the broader international risks as nationalism rises and global cooperation weakens.

Dr. Ramanan Laxminarayan is the Founder and President of the One Health Trust and a Senior Research Scholar at Princeton University. He is also an Affiliate Professor at the University of Washington, a Visiting Professor at the University of Strathclyde, and a Senior Associate at the Johns Hopkins Bloomberg School of Public Health. Dr. Laxminarayan chairs the board of GARD-P, a global product development partnership created by the World Health Organization to develop and deliver new treatments for drug-resistant infections. He is also the founder and board chair of HealthCubed, which works to improve access to healthcare and diagnostics worldwide. Since 1995, he has been a leading global voice on antimicrobial resistance, bringing the issue to the United Nations General Assembly in 2016 and shaping health policy across Asia and Africa through the Global Antibiotic Resistance Partnership.

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Transcript:

Ramanan [00:00:01]
We have crossed the red line where we have completely untreatable infections. Some people tend to think of antibiotic resistance as being a future threat. I do not think of 1.3 million people dying as a future threat.

Dominic [00:00:21]
Hi, I’m Dominic Bowen, host of The International Risk Podcast. Today we explore how antimicrobial resistance intersects with global conflicts, non-state actors, and shifting policies around the world. From disrupted healthcare systems to bioterrorism risks and youth demands for inclusive governance, antimicrobial resistance truly tests humanity’s resilience.

We are joined by Dr. Ramanan Laxminarayan, Senior Research Scholar at Princeton University and a globally recognised expert on antibiotic resistance. He has authored more than 300 peer-reviewed publications, delivered a TED Talk viewed over a million times, and held leadership roles with the World Health Organization and the U.S. Presidential Advisory Council. His work has shaped global health policy, with a focus on conflict zones, biosecurity, and equitable health access.

In this conversation we gain insight into the escalating international risks of antimicrobial resistance and the challenges faced by conflict-affected regions and global governance systems. In an era of rising conflict, authoritarianism, and inequality, antimicrobial resistance, which already claims more than 1.2 million lives annually, is both a silent threat to global stability and a serious international risk.

Dr. Laxminarayan, welcome to The International Risk Podcast.

Ramanan [00:01:38]
Thank you for having me. It’s a pleasure to be here.

Dominic [00:01:40]
Many of our listeners think of international risks as primarily driven by conflict or economic crises. But your work shows that antimicrobial resistance, with over 1.2 million deaths each year, is itself an international risk. How do you see AMR intersecting with the wider global risk landscape?

Ramanan [00:02:07]
That is a great question. Think about what healthcare means to you. Perhaps a family member needed cancer treatment, or a grandparent had a hip replacement, or someone underwent surgery. For all these procedures, we rely on antibiotics.

Antibiotics make chemotherapy possible. They make organ transplants possible. They make routine surgeries, even dental work, possible. When antibiotics fail, people die not from the underlying condition but from infection.

Modern healthcare depends on effective antibiotics, but they are failing more rapidly than we appreciate. And this is not only about people. A large proportion of antibiotics are also used in animals, often to promote weight gain, which accelerates resistance and spreads risk more widely.

Dominic [00:03:47]
This is an issue that has been raised in public debate for at least 15 years, not only among medical professionals. Are we making progress, or is the problem getting worse?

Ramanan [00:04:04]
Unfortunately, the problem is getting worse. Most of the antibiotics we use today were discovered before 1980. Few new ones have been developed since then, partly because they are difficult to find, partly because they are costly to develop, and partly because companies see little profit.

The burden is not evenly shared. In high-income countries, vaccines and better prevention reduce the number of infections. In low- and middle-income countries, infections remain common and are often untreatable. We have reached a point where reliable antibiotics are scarce, and every hospital visit carries risk.

Dominic [00:05:27]
So is the solution simply to develop better antibiotics, or should we focus on prevention before infections arise?

Ramanan [00:05:47]
Prevention is the first step: better water, sanitation, vaccination, and infection control. But prevention alone will not be enough. We also need new antibiotics. Each year 1.27 million people die from untreatable bacterial infections. That is more than HIV and malaria combined. Yet the world treats AMR as a future concern rather than a present crisis.

Dominic [00:07:00]
Why then have governments been so slow to act? During COVID-19, resources were mobilised quickly. Why not with AMR?

Ramanan [00:07:23]
There are several reasons. First, AMR is a slow-moving problem. There has been no single avalanche moment to demand political action. Second, there is little patient advocacy. People die quickly and families often do not even know resistance was the cause. Third, the political incentives are weak. Action on AMR requires long-term investment, but politicians seek short-term wins.

So national action plans exist, but fewer than 35 percent are properly funded. Policymakers understand the problem, but the scale of response is nowhere near the scale of the threat.

Dominic [00:09:32]
Another concern is the heavy reliance on a few pharmaceutical companies. If only a handful are developing antibiotics, are we facing a dangerous monopoly?

Ramanan [00:09:37]
It is true that few large companies remain, but 80 percent of antibiotic development is now driven by small and medium enterprises. These firms are innovative but often go bankrupt even if they succeed. The economics simply do not work. Antibiotics are expensive to develop, yet they are sold cheaply and used sparingly.

There have been funding efforts through agencies such as BARDA in the U.S. and HERA in Europe, but they are still insufficient. The pipeline is fragile, and unless the economics change, new antibiotics will remain scarce.

Dominic [00:11:00]
What about conflict zones? Healthcare collapses during war, and reports show higher rates of resistant infections in places like Ukraine and Gaza. What are the risks?

Ramanan [00:11:11]
Conflict accelerates resistance dramatically. Hospitals are bombed, sanitation systems fail, and field medicine cannot provide proper care. Resistant infections spread quickly in such conditions. And once bacteria learn resistance, they do not forget. Conflict may end, but the resistant strains remain.

We see this clearly in Ukraine and Gaza today, just as we have in past conflicts in Africa and elsewhere. Peace and stability are essential if we want to control infections at a population level.

Dominic [00:13:00]
Can you describe what life on the ground looks like in places facing high resistance?

Ramanan [00:13:31]
It means facing infections that no drugs can treat. Doctors must watch as patients die, not because of their underlying condition, but because no antibiotic is effective. This is the bleak reality we faced before antibiotics were discovered in the 20th century, and it is returning in many war zones today.

Dominic [00:14:42]
Given these challenges, what investments are most urgent to strengthen health systems and improve AMR governance?

Ramanan [00:15:01]
Public health thrives with stability. When governments function, vaccination campaigns work, sanitation is maintained, and outbreaks are controlled. When systems collapse, infections surge.

If we want the benefits of modern medicine, we need stability and, in most cases, democratic accountability. Without that, health systems falter and infections spread unchecked.

Dominic [00:17:00]
What lessons can we take from successful global initiatives in tackling AMR or other health threats?

Ramanan [00:17:09]
Scandinavian countries provide good examples. Sweden was the first to ban antibiotics in animal feed, and others followed. They built systems that reduced antibiotic use while maintaining health and productivity.

Internationally, alliances such as Gavi and the Global Fund show how relatively modest investments can save millions of lives. Vaccines are among the most effective tools against AMR because every prevented infection is one less opportunity for resistance.

Dominic [00:19:13]
In an era of disinformation, how do we build public awareness and political momentum on an issue as complex as AMR?

Ramanan [00:19:34]
We need international cooperation. Antibiotic resistance spreads like climate change: one person’s misuse affects everyone. There have been UN resolutions on AMR, but we need more tangible commitments. The Montreal Protocol on ozone depletion is a good model of collective action.

Dominic [00:21:48]
What role can youth play in this?

Ramanan [00:22:14]
Youth populations are large in many countries, and they can make a difference through consumer behaviour and advocacy. For example, much of the poultry consumed worldwide is raised with daily antibiotic use. If consumers demand antibiotic-free meat, producers will change. We have already seen this happen in the United States.

Dominic [00:24:27]
What are the next warning signs governments should be watching?

Ramanan [00:24:44]
We are already there. We have untreatable infections today. The UN has set a modest target of reducing AMR deaths by 10 percent by 2030, but we should aim much higher. With cooperation and political will, we could save 1.3 million lives each year.

Dominic [00:25:36]
When you look at international risks more broadly, what concerns you most?

Ramanan [00:25:41]
The erosion of trust and cooperation. We see genocide in Gaza, widespread conflict, and governments acting with hypocrisy. Trust in science is declining. Trust in institutions is declining. Without cooperation, our ability to solve collective problems is collapsing. That is my greatest concern.

Dominic [00:28:12]
Thank you for raising these important issues, and thank you for joining us on The International Risk Podcast.

Ramanan [00:28:16]
My pleasure. Thank you for having me.

Dominic [00:28:18]
That was Dr. Ramanan Laxminarayan, Senior Research Scholar at Princeton University and one of the world’s leading experts on antimicrobial resistance. His insights show how AMR is not just a health crisis but a geopolitical flashpoint.

I’m Dominic Bowen, host of The International Risk Podcast. Thank you for listening. We will speak again next week.