We must heed the World Health Organization’s warning: “Without urgent action, the world is headed for a ‘post-antibiotic era’ in which common infections and minor injuries which have been treatable for decades can once again kill, and the benefits of advanced medical treatments such as chemotherapy and major surgery will be lost.” It’s hard to overestimate the dire impact of a return to such a world, yet the challenge we face is getting millions of people to curb their use of drugs now, before that happens.

In the simplest terms, antimicrobial resistance’s fundamental problem is the misuse and overuse of medications to treat infections, which lead to drug-resistant pathogens. What if we could avert millions of infections in the first place, dramatically reducing the need for medication? Fewer infections would mean fewer opportunities for misuse and overuse.

From COVID-19 to cardiovascular disease, to protect the health of the public, public health focuses on preventing illness and disease. We should approach antimicrobial resistance no differently. Speaking at the World Health Assembly in 2019, Dr. Tedros Adhanom Ghebreyesus, Director-General of WHO made that clear, “if you can’t do the basics [like provide soap and water], then forget the rest. Prevention, prevention, prevention.”

The good news is we have such a method of prevention — one with a long and tried-and-true history. Reflecting upon the 20^th century, the Centers for Disease Control and Prevention identified clean water and sanitation as one of the crowning public health achievements in the U.S. In the UK, the so-called ‘sanitary revolution’ has been hailed as a shining victory of science, dating back to the 19^th century with John Snow and the Broad Street Pump.

The singular effectiveness of access to clean water, sanitation and hygiene, called WASH, in preventing the spread of disease is well understood, yet billions of people around the world still lack access to these necessities. COVID-19 has shown a damning light on these inequities. Currently, 2.1 billion people live without access to safe drinking water and 4.5 billion people are without access to adequate sanitation. Every day, 1,300 children under 5 die from preventable diarrheal diseases, including cholera, caused by contaminated water and poor sanitation. Perhaps most unbelievable: 1 in 3 healthcare facilities lacks soap and water or hand sanitizer where staff provides patient care. Billions of patients worldwide must rely on these facilities.

It is in the healthcare facility, with its high density of both vulnerable patients and pathogens, that access to these essential services becomes even more consequential. Hygiene must be top priority. It is crucial that doctors and nurses can wash their hands, disinfect their equipment, and clean their environment. And yet they cannot. When up to 90% of women in a given country receive routine prophylactic antibiotics during child birth, we must re-examine the conditions under which they are delivering their babies and what would cause the inevitability of infection.

The cumulative lack of WASH adds up to children and adults not only getting unnecessarily sick — with the associated suffering, medical costs and loss of income or schooling — they are relying on antibiotics to get better. The challenge here is that WASH is a public works solution for a public health problem. WASH is not a pill or “quick fix”. It requires capital investment, system strengthening, and behavior change to ensure that clean water and functional toilets are available and utilized day in and day out. These issues require a different set of skills than those possessed by medical and public health professionals.

A change in prioritization is required. Global health leaders and policymakers must move from investing solely in disease treatment to an emphasis on prevention. We need those working on antimicrobial resistance to advocate for WASH as a top priority, in addition to new drug development. We need doctors and nurses on the frontlines to demand water and soap at their healthcare facilities and teach patients about prevention through hygiene. We need facility administrators to include WASH operations and maintenance in their budgets and national policymakers to bring together experts in public health and public works to plan and implement sustainable WASH in healthcare. And we need donors to support countries in their plans.

Cost is always a driver. But WASH is the “best buy” for antimicrobial resistance, with hygiene implementation possible even where resources are limited. Every dollar spent on WASH, in fact yields an estimated $4.30 in gains in better health and increased productivity. But an even more significant driver than cost should be the harrowing idea of going back to a time without adequate antibiotics. We’re in a fierce fight against antimicrobial resistance; it is incumbent on us to use every tool at our fingertips. Doubling down on proven prevention measures which save both lives and livelihoods is smart investment.

As Dame Sally Davies has deftly said, “We are in an arms race against microbes, which are expert at evolving resistance rapidly, so we have to respond quickly and in a multifaceted way.” We have the tools, we know our mission, and the clock is ticking.

Lindsay Denny, a senior public health program associate for the Center for Global Safe Water, Sanitation and Hygiene at Emory University, is the health adviser for Global Water 2020.

***

Initial response from BSAC

If someone told you there was a way to prevent many diseases and, in turn, tame the spectre of antimicrobial resistance, you’d listen. Wouldn’t you?

Well, that someone, on this occasion, is Lindsay Denny. But she’s only repeating what many others have said over many decades: that access to clean water, sanitation and hygiene, are of fundamental importance to global health. If people don’t get sick, they don’t need drugs, and if they don’t need drugs, drug-resistant infections can’t pose the existential threat they do now.

And yet, despite the obvious truth of what’s being said, billions of people still don’t have access to clean drinking water, or adequate sanitation (WASH).

That must change, but is only likely to do so through a radical rethink of our priorities – so that prevention is taken as seriously as treatment.

This should start with the people in our network advocating for WASH as a top priority, alongside drug development and stewardship.

But we also need, as Lindsay says, doctors and nurses on the frontlines demanding water and soap at their healthcare facilities and to teach patients about prevention through hygiene.

To do our bit, BSAC is today committing to support a WASH project through its global health initiative Stop Superbugs. As soon as a partnership has been agreed, we’ll call on you, our friends and colleagues, for support.

But first, we want to hear your thoughts on Lindsay’s article. What you say could inform the recommendations we make in the Vanguard Report itself, which will be published at the end of the year.

You can join the conversation by emailing mcorley@bsac.org.uk or tweeting our @BSACandJAC account.