The world’s governments have agreed on actions to address the challenge of antibiotic resistance. This raises the question of what level of national action is associated with improved outcomes, including both slower growth and lower levels of antibiotic resistance. Answering this question is challenged by variation in data availability and quality as well as disruptive events such as the COVID-19 pandemic. We investigate the association between level of national action and temporal trends in multiple indicators related to health system capacity, antibiotic use (ABU), absolute rates of resistance (ABR) and a Drug Resistance Index (DRI). Using the Global Database for Tracking Antimicrobial Resistance (TrACSS) to construct an index of national action, we apply cross-sectional regression across 73 countries to estimate the association between the level of action in 2016 and trends in national indicators (2000–2016). We find that national action is consistently associated with improved linear or categorical trends in all groups of indicators. Reductions are associated with a relatively high action index (range 0–4) for ABU (median 2.8, 25–75% quartile 2.6-3.3), ABR (3.0, 2.4-3.4), and DRI (3.5, 3.1-3.6). These associations are robust to the inclusion of other contextual factors related to socio-economic conditions, human population density, animal production and climate. Since 2016, a majority of both Low- and Middle-Income Countries (LMICs) and High-Income Countries (HICs) report increased action on repeated questions, while one third of countries report reduced action. The main limitations in interpretation are heterogeneity in data availability and in when actions have been implemented. Our findings highlight the importance of national action to address the domestic situation related to antibiotic resistance and indicate the value of both incremental changes in reducing adversity of outcomes and the need for high levels of action in delivering reduced levels of resistance.

Background: The concept of planetary health underscores the intricate relationship between environmental concerns and global health. This interconnection raises an important question related to cross-sectoral policy development: to what extent are environmental issues integrated into global health governance? To address this question, this study examines resolutions adopted by the World Health Assembly (WHA) from 1948 to 2023. Methods: Based on a systematic text search for environmental issues, this study examines the evolution of the occurrence and content of resolutions adopted by the WHA and the structure and pattern of connectivity of the normative network of resolutions regarding environment-related resolutions from 1948 to 2023. Environment-related resolutions were processed in the Python environment using relevant packages, such as Pandas, Numpy, and Matplotlib. Regular expressions were employed to identify citations among resolutions and construct a directed citation network. The network was then examined using NetworkX and Graph-Tool. Findings: Despite important variations in the attention dedicated to environmental issues in resolutions adopted by the WHA, the proportion of environment-related resolutions adopted each year has increased. The number of topics and their diversity have also expanded. Although environment-specific resolutions are well connected to each other, they are more weakly connected to environment-related resolutions, and not well connected to non-environment-related resolutions, suggesting potential silos in policy development. This study shows that several topical entry points exist for a deeper integration of environmental concerns in global health governance. Interpretation: The findings of this study indicate not only the growing reference to environmental concerns in global health governance, but also an evolution of the understanding of the environment as a key driver of the health of the people. However, there remains room for more comprehensive integration across all areas of global health policy. The study emphasises both the need for active participation in global environmental governance processes that affect health and the importance of minimising the health sector's contribution to environmental problems. Funding: None.

Non-Technical Summary. Several transnational corporations, investors, international organizations, and philanthropies have formed coalitions to respond to global social and environmental challenges. Do these coalitions, consisting of large-scale actors, have the capacity to contribute to the sustainability transformations that are needed, or do they perpetuate the same systemic dynamics that created the problems in the first place? We investigate this question by comparing publicly available information from five coalitions working on financial and food systems sustainability. Technical Summary. This paper examines whether large-scale actor coalitions (LSACs) may contribute to transformations toward equitable and sustainable futures. We use a ‘rapid assessment’ 20-variable framework to collect and analyze empirical data from five food and finance coalitions to identify their roles and capacities for transformative change. Our results indicate that LSACs implement distinct strategies to reach their goals. More specifically, due to their diverse set-ups, LSACs have the ability to raise awareness of sustainability issues, utilize ties to push forward agendas, engage in institutional policy-shaping processes, experiment with solutions, and showcase promising niche initiatives. We identify ways that LSACs’ actions can enable efforts of other change-makers who aim to change the food and finance systems and contribute to systems with high and diverse capacities for transformative change. We also discuss why the roles and lack of certain capacities of LSACs might hinder the creation of enabling conditions for transformative change within the food and finance sectors. Social Media Summary. Coalitions consisting of powerful actors have a range of transformative capacities that, under certain conditions, can support systemic transformations within their sectors.

Background Sustainable development goals (SDGs) may play a pivotal role in mitigating antimicrobial resistance (AMR). This study examines how countries can integrate AMR mitigation with sustainable development strategies, providing evidence on the prioritisation of AMR-related efforts within both agendas. Methods We conducted a comparative analysis of the international global action plan (GAP) and national action plan (NAP) on AMR and SDGs across 10 countries in Africa and Asia. We employed content analysis to map actions to AMR drivers, descriptive statistics to summarise the coverage and focus of the actions and inferential statistics to explore factors associated with the level of policy alignment. Results Our findings highlight gaps in the current AMR policy landscape, where drivers are at risk of being redundantly addressed, narrowly focused or entirely overlooked. At the international level, over 50% of AMR drivers are addressed by both frameworks, but national-level overlap is lower (10.5%-47.4%), with Asian countries showing stronger alignment than African countries. Asian countries show a higher proportion of shared drivers than African countries. A considerable proportion of drivers are addressed solely by AMR-NAPs (23.7%-60.5%) or SDG-NAPs (13.2%-31.6%), raising concerns that actions may benefit either sustainable development or AMR at the expense of the other. Finally, 10.5%-26.3% of drivers, mostly distal, are not acknowledged by either framework, highlighting potential policy blind spots. Conclusions The Agenda 2030 includes ambitious and cross-cutting goals with GAP-AMR, therefore it can facilitate intersectoral collaboration in addressing AMR. The effective implementation of both agendas will depend on national governments' capacity to ensure that efforts in combating AMR also contribute to sustainable development.

Introduction: Antimicrobial resistance (AMR) is a multifactorial challenge driven by a complex interplay of proximal drivers, such as the overuse and misuse of antimicrobials and the high burden of infectious diseases, and distal factors, encompassing broader societal conditions such as poverty, inadequate sanitation, and healthcare system deficiencies. However, distinguishing between proximal and distal drivers remains a conceptual challenge.

Objectives: We conducted an umbrella review, aiming to systematically map current evidence about proximal and distal drivers of AMR and to investigate their relationships.

Methods: Forty-seven reviews were analysed, and unique causal links were retained to construct a causality network of AMR. To distinguish between proximal and distal drivers, we calculated a ‘driver distalness index (Di)’, defined as an average relative position of a driver in its causal pathways to AMR.

Results: The primary emphasis of the literature remained on proximal drivers, with fragmented existing evidence about distal drivers. The network analysis showed that proximal drivers of AMR are associated with risks of resistance transmission (Di = 0.49, SD = 0.14) and antibiotic use (Di = 0.58, SD = 0.2), which are worsened by intermediate drivers linked with challenges of antibiotic discovery (Di = 0.62, SD = 0.07), infection prevention (Di = 0.67, SD = 0.14) and surveillance (Di = 0.69, SD = 0.16). Distal drivers, such as living conditions, access to sanitation infrastructure, population growth and urbanisation, and gaps in policy implementation were development and governance challenges, acting as deep leverage points in the system in addressing AMR.

Conclusions: Comprehensive AMR strategies aiming to address multiple chronic AMR challenges must take advantage of opportunities for upstream interventions that specifically address distal drivers.

How did human societies evolve to become a major force of global change? What dynamics can lead societies on a trajectory of global sustainability? The astonishing growth in human population, economic activity and environmental impact has brought these questions to the fore. This theme issue pulls together a variety of traditions that seek to address these questions using different theories and methods. In this Introduction, we review and organize the major strands of work on how the Anthropocene evolved, how evolutionary dynamics are influencing sustainability efforts today, and what principles, strategies and capacities will be important to guide us towards global sustainability in the future. We present a set of synthetic insights and highlight frontiers for future research efforts which could contribute to a consolidated synthesis.

In the face of growing societal, public health and environmental challenges linked to the functioning of the biosphere, strong evolutionary literacy emerges as indispensable to plan and achieve sustainable futures. However, research on evolution education has mainly focused on the content taught in classrooms, leaving its application to sustainability issues largely unexplored. Given this, in this paper, we suggest an integrated view of biological evolution education and sustainability education. For that, we argue for the pivotal role of evolutionary literacy to address diverse sustainability issues and for the development of key competencies in sustainability, namely systems thinking and anticipatory competencies. To support the implementation in classrooms, we propose educational strategies to promote evolutionary literacy, systems thinking and anticipatory competencies through socioscientific issues linked to sustainability topics. Finally, we identify future research needed at the intersection of evolution education and education for sustainability to effectively promote evolutionary literacy and the development of key competencies in sustainability. With this, we aim to contribute to further enhancing education for sustainability through the lens of evolution.

The intensification of aquaculture industries around the globe has led to increased susceptibility and exposure to diseases. To ensure the well-being of animals and the profitability of the industry, many aquaculture farms resort to antibiotic treatments. However, with the increasing presence of antimicrobial resistance (AMR), it has become important to regulate and limit the use of antibiotics, especially in animal production and regarding the antibiotics that are deemed as critically important for human health by the World Health Organization (WHO). This review describes how AMR mitigation strategies have developed over time in international settings and how they relate to aquaculture. Furthermore, we analyzed how different countries and regions abide by these statutes, as well as the antibiotic standards from a selection of certification schemes. Our results show that the role of aquaculture has been inexplicitly addressed in international guidance documents and that there is a need to further increase the activities of aquaculture operations in combating AMR, with an emphasis on alternatives to antibiotic use. We also found that most countries and regions allow the highest priority-, or critically important antibiotics in aquaculture, which could have detrimental effects on animal, environmental, and public health. As a result, most countries fail to comply with the recommendations and standards set by international organizations and certification schemes.

The rapid, human-induced changes in the Earth system during the Anthropocene present humanity with critical sustainability challenges. Social–ecological systems (SES) research provides multiple approaches for understanding the complex interactions between humans, social systems, and environments and how we might direct them towards healthier and more resilient futures. However, general theories of SES change have yet to be fully developed. Formal evolutionary theory has been applied as a dynamic theory of change of complex phenomena in biology and the social sciences, but rarely in SES research. In this paper, we explore the connections between both fields, hoping to foster collaboration. After sketching out the distinct intellectual traditions of SES research and evolutionary theory, we map some of their terminological and theoretical connections. We then provide examples of how evolutionary theory might be incorporated into SES research through the use of systems mapping to identify evolutionary processes in SES, the application of concepts from evolutionary developmental biology to understand the connections between systems changes and evolutionary changes, and how evolutionary thinking may help design interventions for beneficial change. Integrating evolutionary theory and SES research can lead to a better understanding of SES changes and positive interventions for a more sustainable Anthropocene.