From discovery to preparedness: reframing antimicrobial resistance as a global governance challenge

Almost a century after the discovery of penicillin, the antimicrobial resistance (AMR) crisis has become as much a failure of global governance as a biomedical challenge. Published Global Burden of Disease estimates for 2000-2021 show a persistent geographic hierarchy of mortality, a pattern consistent with AMR burden being embedded in health system capacity rather than due to pathogen evolution alone. Furthermore, the for-profit pharmaceutical model remains structurally misaligned with the clinical necessity of restricted antibiotic use. This Perspective argues that the next phase of AMR mitigation must pivot from a discovery-dominated paradigm to an integrated preparedness model in which innovation, stewardship, surveillance, and governance are collectively strengthened. We contend that success will be determined less by laboratory and technology breakthroughs than by the political commitment to decouple revenue from sales volume and to govern antimicrobial effectiveness as a shared, exhaustible resource. We propose a coordinated policy toolkit - integrating "push-pull" incentives and One Health surveillance - to protect the epidemiological utility of these finite resources. The antibiotics era began as a story of discovery, became a story of complacency, and must now become a story of stewardship and global governance.