CONTEXT

For more than 4,000 years, the Mediterranean basin has been a strategic crossroads where health, economic, and environmental challenges intersect. This region—rich in history and stretching from the Middle East to Europe, Africa, and Asia—has long served as a hub for trade and cultural exchange.

Today, the Mediterranean remains a densely populated ecosystem, with nearly 150 million inhabitantsalong its 46,000 km of coastline. Although it represents only 0.8% of the global ocean surface, it hosts around 10% of worldwide biodiversity, including a vast and diverse microbial ecosystem.

Over millennia, this biodiversity has evolved under the influence of human activity and climate change, making the Mediterranean a unique environment where microbes and their genetic traits can circulate between humans, animals, and the environment. This makes the region particularly sensitive to issues such as antimicrobial resistance (AMR), pharmaceutical pollution, and environmental contaminants.

The region faces rapid transformations:

• Growing tourism
• Heterogeneous demographic trends
• Variable social and health behaviors
• Highly unequal healthcare systems
• Insufficient waste and wastewater treatment, especially in coastal areas

Meanwhile, antimicrobial resistance—a major One Health concern—causes an estimated 1.14 million deaths per year, 90% of which occur in low- and middle-income countries.

AMR in the Mediterranean is driven by biological factors (antimicrobial and pharmaceutical use, pollution from human activities, climate change) and non-biological factors (healthcare access, social behaviors, waste and wastewater management).

This unique convergence makes the Mediterranean a high-risk region for the emergence and spread of antimicrobial-resistant bacteria.

Efforts to combat AMR are hindered by:

• Fragmented surveillance systems
• Limited data on antimicrobial use and resistance
• Inappropriate antibiotic practices in humans, animals, and aquaculture
• Insufficient research on environmental pollution (pharmaceuticals, pesticides, biocides)
• Emergence of multidrug-resistant clones specific to the region
• Lack of regional coordination in education, training, and research

There is a clear need to bring together experts, harmonize data, strengthen capacity building, and enable evidence-based actions.

The Union for the Mediterranean, created in 2008, laid the foundations for regional cooperation. MediCA²Cemerges as a concrete and timely initiative to take this vision further.