Can mass antibiotic administration save young lives today without exacerbating the long-term risks of antimicrobial resistance (AMR) in future generations?
That’s the question behind a new study co-authored by York University Associate Professor A.M. Viens, which examines the global debate over mass drug administration of azithromycin (MDAA) in high-mortality regions.
Research shows that giving children in these regions the common antibiotic azithromycin through MDAA programs – ranging from a single dose to periodic treatments – can lower deaths from infections like pneumonia, diarrhea and malaria. Trials in sub-Saharan Africa present significant reductions in child mortality with the use of MDAA, the study reports.
The World Health Organization (WHO), however, has been cautious about recommending this approach over concerns that it could accelerate AMR.
The study, published in PLOS Medicine, argues that current WHO guidelines may overlook critical ethical considerations. Viens and co-authors call for more equitable, locally informed policies that support long-term health and equity.
The authors urge global health leaders to reconsider current WHO guidelines that limit MDAA use and instead move toward approaches based on local risk and need. They also highlight the importance of investing in stronger health systems and improving access to antibiotics.
Countries that are expanding MDAA to reduce child deaths have formally agreed to closely track antibiotic resistance and child mortality as part of the implementation.
“It’s time to revisit the 2020 WHO guidelines. New evidence shows MDAA can save lives with manageable risks, and countries can do so responsibly with the right safeguards and support systems in place,” says Viens, who holds a York Research Chair in Population Health Ethics and Law. "Ethical stewardship must balance equitable access with sustainability – especially for the communities most in need.
“Saving lives now and protecting future generations from resistance are both important goals, which must involve a fairer balance of benefits and burdens between high-income and low- and middle-income countries.”
Global AMR policies often prioritize protecting antibiotics over making them accessible, the study reports, which can unfairly affect low-income countries, while wealthier countries have contributed more to the rise of AMR but face fewer restrictions.
Ethical frameworks must reflect real-world conditions, says Viens. “We need to move beyond one-size-fits-all policies. Global health decisions should be shaped by context, equity and the lived realities of those most affected.”
Updating WHO guidelines to allow context-specific use of MDAA, set clear monitoring thresholds and support long-term access could better reflect the WHO’s commitments to equity, human rights and addressing the root causes of poor health, the study suggests.
Viens hopes the study will spark discussion among public health experts and ethicists, with its recommendations used as a reference to influence future WHO policy updates.
Read the full article “Whose burden, whose benefit? Revisiting ethical trade-offs in the WHO guidelines on scaling up mass azithromycin administration.”